P - 84444RE�UEST FOR ELECTRICAL INSPECTION ¢�`�"�� ee-0000,-oe
r � See instructions for completing this torm on back of yellow copy. ���g`
� ��
,��'41213 X" Below Work Covered by This Request ���
.
ew Add Rep. TypeofBuilding AppiiancesWired EquipmentWired
Home Range Temporary Service
Duplex Water Heater Electric Heating
Apt. Building Dryer OtheF-LSpecify)
Comm./Industrial Furnace
Farm Air Conditioner
Other (specify� Contractor's Remarks: �@pj y�QY� Q X N- ��`�c�
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Compute Inspection Fee Below: ,Q�����t/,�
# Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Swimming Pool 0 to 200 Amps 0 to 100 Amps
Transformers Above 200 Amps Above 100 Amps
Signs Inspector's Use Only: TOTAL
Irrigation Booms �,� �
Special Inspection
Alarm/Commun t' �. THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT
Other Fee COMPLETED WITHIN 18 MONTHS.
I, the Electrical Inspector, hereby Rough-in �'� Date� g
certify that the above inspection has Final o
been made. � Z-`d ��
OFFICE USE ONLY
Thi9 request void 18 months from '
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K41.213 ���
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�Request Date Fire No. Rough-in Inspection �
7� �� Required? ❑ Ready Now ill Notity Inspector
� a Yes No When Ready?
I licensed contractor p owner hereby request inspection of above electrical work at:
Job Address (Street. Box or Route No.) City�� � � j
lo(o �r �! ,� �
Section No. Township Name or � Range No. County
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Occupant(PRINT� . , Phone No.
Power
`C �i ii. � C.l
g Address IContracror o�
D�i� �Y,n
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LS /�.�U ..lJ/ flls/�
Contractor's License No.
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G� -6 ��
MINNESOTA STATE BOARD OF ELECTRICIT � ['� THIS INSPECTION RE�UEST WILL NOT
Griggs-Midway Bldg. — Room S-173 �'•/ �� BE ACCEPTED BY THE STATE BOARD
1821 Universfty Ave., St. Paul. MN 55104 �" � UNLESS PfiOPER INSPECTION FEE IS
Phone (612) 642-0800 ENCLOSED.