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Home Duplex
Commercial Industrial
Air Cond. Htg. Equ
Dryer Range
"X" above the work covered b
REQUEST FOFi ELECTRICAL INSPECTION �°"
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800 `'�'
Apt. Bldg. Other: .DD New Addn
Farm � �1��� Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heaf Temp. Service
request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will r.ot be accepted without ihe correct fee:
Other Fee # Service Entrance Size Fee # ircuits
Mobile Home Park Stall 0 to 200 Amps to 100 A
Street Ltg./Traffic Sig. Above 200 Am s Above 100
Fee
Transformer/Generafor INSPECTOR's u ONLY TOT�A/L
Sig�/Outline Ltg. Xfmr. 3� A' S�� %���' �7� S�
Alarm/Remote Control �C'
Swimming Po�l r.,� �^�%'`-- � ��' ��
I fieke6"certi that I ins the elechical installation escn her n on the d tes stated
lrri9ation B RougMn Dare
Speciallnspection ' — �g �����
Finaf D
Investigative Fee � �. G�
THIS INSTALLATIOTf MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months kom validation date printed in this box.
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* 0 8 0 2 1 8 2�� ����
PLEASE PRINT OR TYPE
Request Dafe �� Rou h-in ins oa r uired$ Yes
y� g pecti eq ❑ No Inspection Other Than Roughdn: ❑ Ready Now Will Call
3'` 1Q G 14 � O�O (You musf call fhe inspector wh n ready� Dafe Ready:
I, ❑ licensed conhacror � owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.� Ciy Zip Code
S 7S G H� � k yYt o�, /'-/r r�� l-� h's'�t'3 Z.
Section No. Township Name or o. Ronge o. Fire No. Counly
�� �� �� d ,\ �
Occupant Phone No.
l.ti a al e Co r 3 o vl - jj' ��
Power Supplier Address
S� �"� �S /ald or �-� I.7�'Y,�S ' o�
Elechical Contractor (Company Name� Conhador licen:e No. Mas4er Lic. No. (Plant Elecl. Only)
p U�h�Y'
Mailing Addreu �Conhacfor or Owner Performing Installafion�
5 a'�'vt � o s q� ,6 0� v e
Authorized SignaNre (C haMor Owner Performirg Insf � Phone No.
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EBO0001 A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY