P - 83252RE(�UEST FOR ELECTRICAL INSPECTION
6 Z 4��(` � � Minnesota State Board of Electricity
r �� 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 this request. Enter remarks in this space and on the back of the white copy only.
�o� C� O�,t��n "7�1� � 1 ��S
Ca(culate Inspection Fee - Tliis Inspection Request wil! not be accepted wifhoui fhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders 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
Boom
ihat I inspecFed fhe elecirical insfallation described herein on fhe dates stated
Dafe
� Irnestigative Fee � U�, j, tij � � �/' ��C J
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF MOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation date printed in fhis box.
II�IIIllllllllll�llll�lllllli��l�l�ll�l � ���
* 0 6 7 4 3 6 1 1* �OLi��
PLEASE PRINT OR TYPE
Request D te Rough-in inspeclio� required$ ❑ Yes No Inspecfion Other Than RougMn: ❑ Ready Now Will Call
��[ ��� (You must call fhe inspector when ready� Date Ready:
1, �licensed contractor ❑ owner hereby request inspection of the above electrical work aF:
lob Address (Sheef, Box, or Roule No.) Ci Zip Code
q t�aC.l�n�Gl,h G r. �r� oU 5� �
Secfion No. Township Name or No. Range No. Fire No. Counly
�U�'h � �b � ��YY1p�SfSY� I �'� 5-1 �i' ' �-(o
� Addrezs
ai �,� ��.om ny �ya�•. �•
I7�lV� I�I�I
.�� �►�E. N.E.
Mailing Ad _:i q�or EP��rypjng Installa
(Co acfor er P rfo�mlhg Instalkfioq) �/�3 r.. ��� ? Phone N� �
� dv � � � �
.. . ..,,.-' -.::,�1'AI�''BQpRb'B�AIG*-�SEE�4NS'FRUCTIONS ON BACK OF YELLOW COPY