P - 83450REGIUEST FOR ELECTRICAL INSPECTION �
7� J= 6 3 0� Minnesota State Board of Electricity ��'
1821 University Ave., Rm. S-128, St. Paul, MN 55104 ���
Phone(612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enier remarks in this space and on the back of the white copy only.
CHANGE EXISTING FUSE PANEL TO CIRCUIT BREAKER PANEL/INSTALL 2
KITCHEN RECEPT./WIRE AIR OND & FURNACE FOR A TOTAL OF 5 CIRCUIT5.
�o �b C1 Q-u-�n � 7�-7g �S
Calculate Inspection Fee - This Inspecfion Request will not be accepted without ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps ,b-p
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAI,���'�
r1 _�
Sign/Outlme Ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool
Irriqation Boom
I insoecled the elechical insfallafion deuribed herein on the dafes sfated
Investigative Fee - J
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONT .
OFFICE USE ONLY This requesf void 1 S months from validafion date printed in fhis box: �
���� �� ��f II ��I If �fi I� ��� �I�1�� I� 1� �l � � ��I � d� `�'
* 0 7 1 5 6 3 0 0* �ll�
PLEASE PRINT OR TYPE
Reques D fe Rough-in inspection requ+redR ❑ Yes Inspection Ofher Than Rough-In: ❑ Ready Now ill Call
�� '� g (You must call fhe inspector when ready) Date Ready:
I, ensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheef, Box, or Route No.) City /� Zip Code
/"A i 1 .. • � � _ �n _ _ . I� _ 1� J/ � _ _ f C/ � '�'1
or
Power
Elechical Conhacfor �Company Name)
BLJIN�E Hi�9. AF�C ELECT., INC.
Mailing Add i i 1 eMllation)
ANOi 55;�n�
Aufhorized 5 ture (Con acfor o ner PerForm�g Insfallafion)
Fire No. C6unty� �
Phon��' _ � � �
Confracfor License No.
A-1 118/96_, , ,p7.�TE B@ARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
No.
���