P - 82295�0��215 �
Home Duplex
Commercial Industrial
Air Cond. Htg. Equi
Dryer Range
"X" above the work covered b
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Apt. Bldg. Other/ � New
Farm � U �C R-(„o.�. L2 Remod
Water Htr. Load gmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in ►his space and on the back of the white copy
�T� � 1 .. 3 �. o'�--
Calculaie Inspection Fee - This Inspection Request will not be accepted witlfout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Ai
Transformer/Generator INSPECTOR�s use oN�v / TOT,
Sign/Oudine Ltg. Xfmr. Q�,� �_ � jf+-'�C.—�o�}� °
Alarm/Remote Control �l� �_ �f-�
o � /�
� ��
Addn
Fee
/-J O
Swimmin Pool � �- �'�—�1@�
I hereb certi fhat I ins ihe elecirical insfallafion descri herem on Ihe ates s
�f�19O}IO �Y' Rou Mn Da
�--°-� �----� --
9 CZ s- A/ %% -� %� d0
Investigative Fee - /�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHI 1 ONTHS.
OFFICE USE ONLY This requesf void 18 monihs from validation daie prinfed in fhis box.
{ IIII �� III II III I� II) II III II III�I III II III I(III �
* 0 8 0 2 2 1 5 4* ��/` �� � i��° /
PLEASE PRINT OR TYPE
Requesf Dafe Rou h�in ins on r uired$ ❑ Yes
g pecti eq ❑ No � Inspection Other Than RougMn: ❑ Ready Now � Will Call
�'� �� (You must call ihe inspecfor when ready) Dafe Ready:
I, ❑ licensed contractor ❑ owner hereby request inspecfion of the above electrical work at:
lob Address �Sheet, ,Bo� Route No.) Ciy Zip Code
�9�� C�a��ti �v� ��t�� Ss 3�
Section No. Township Name o�,jJo. Range+N�o. - Fire No. oun�� �
OCV d 7
Occupant Ph�on N
�rti %�. r�- i'z- 16��� .S�/- 93sS-
Name)
or Owner Performing Installation�
� �
iMor or Owner Performina Insfalla
{ �P�s ��� �1 �,���Q,v
Conkacfor License No. Masfer Lic. No. (Plant Elect.
STATE BOARO COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
No.