P - 83245. , REGIUEST FOR ELECTRICAL INSPECTION �
5���� ��� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone (612) 642-0 00
Home Duplex Apt. Bldg. Other. �� �� New Addn
Commercial Indusfrial Farm emod Re air
Air Cond. Htg. Equip. Water Hfr. Load Mgmt. Other:
Dryer Ronge Elec. Heat Temp. Service
"X" above ►he work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspecfion Request will nof be accepted wifhout fhe correct fee:
Other Fee # Service EMrance Size Fee Circuits/Feeders Fee
Mobile Home Park Stall 0 ro 200 Amps 0 to 100 Amps
$treet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
TransFormer/Generator INSPECTOR'S USE ONLY TOTAL�/ [�
Sign/Outline Ltg. Xfmr. �-�"��/' � ��
Alorm/Remote Control ��(, �-Cc� '^
Swimming Pool � �C '�� � �
I ceni thar I in the elecrrical installation described herei on dares sta�ed
Irrigatidn Boom Ro�M� Da
Special Ins � �^ Z ���
Fi�wl
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFRCE USE ONLY This request void 18 months from validation date prinfed in �is box.
I II � .�� 5�
IIIIIIII�IIIIIIIIIII lll������1��������l��l � ��a
* � 5 3 2 5 2 3 8�IC PLEASE PRINT OR TYPE
Requesf Dale �_�� R h-in i on uired? Yes
oug nspecfi req ❑ No Inspacfion Olher Than RougMn: ❑ Ready Now Will Call
�, (Nou musf call Ilie inspecror when ready) Dafe Ready:
I, ❑ licensed conhacror �owner hereby request inspecFioo of ihe above elechical work at:
Job Addreu (Sheet, Box, or Roule No.� Ciy Zip Code
5c�3-T A�� �/}MN �V�e, �t-R-� D Le S�-3
Seclion No. Township Name a No. Ra Fire No. Coun
3 0 �� ,�-rv o I�-
o«opoor rh�e No.
TN� N�,AS M., GZV w� Z S7Z-Z� S�
Power Supplier Address
I� S 5 8 37 ��/-�-u�vut�4-N'N /�%` �
� Eleckical Confracror (C y Name� � � Conhacfor License No. Master Lic. No. (Mant Elecf. Only)
Mailing Addreu (Conh«tor or Owner Performing Inslallati
�5�37 ,��NN � dZC D 1'��l% � 5543 Z_._
Aulhorized Si a Ow�er P Phone No. �
-- � f��`�^�`�
EB00001 A-11 6/96 gTA7E BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY