P - 8064679,�-920 �
i�
Home Du lex
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity 3
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �`
Phone (612) 642-0800
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 this request. Enter remarks in this space and o the back of the white copy only.
rdfJ � ��L�JLIJV / l
(�SI-�i�� -���5
Calculate Inspection Fee - This Inspection Request will not be accepted without the correcf fee:
Other Fee # Service Entrance Size Fee # CircuilsJFeeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. .�
Alarm/Remote Control
Swimming Pool
I hereb ceAi that I ins ted the elechical installafion dexribed herein on the dates stated
Irrigation Boom RougMn Dare
Special Inspecti
Final
Investigative Fee
_ THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion date printed in this box.
IIIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIIIIIII�IIIN ��s� � y���
* 0 7 9 9 9 2 0 4*
PLEASE PRINT OR TYPE
Request Dare Rough-in inspection required$ ❑ Yes No Inspection Other Than Rough-In: ❑ Ready Now ill Call
�-- (� Q q (You musf call the inspector when ready) Date Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electricol work at:
Job Address (Sheet, Box, or Roufe No.) City • Zip Code
q t�o t� ac.�!..�na.h Ci r ��c� L Ss43Z
Section No. Township Name or No. Range No. Fire No. Cou ty
Occupanf
�
Power Supplier �
I �����s
Phone No.
s� � -ZZ�
'.�'NC. Conhactor
N.E.
� ��5roua��o��
�..��niuc ermr`ngrnsmi YhoneNO.
� 1
" U��.t,� � 4 � s� --(n 20-0
v
�• STATE.BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY