P - 79405ry RE4UEST FOR ELECTRICAL INSPECTION �'"�
�O G- 3 6 6� 8'21eUniv rstity A earRm. 5-128,ISt Paul, MN 55104 ����
Phone (612) 642- 0 6£ ,-'
/
� Home Duplex Apf. Bldg. i Other: / 00 m�S� New Addn
Htg. Equip. Woter Hfr. Load Mgmt Ofher
Range Elec. Heaf Tamp, Senice
work covered by �his request. En�er remarks in this spoce and on
Calculate Inspection Fee - This lnsp<
Other Fee
Mobile Home Park Stall
�n Request will noY be accepted wifhou� fhe correcf fee:
# Service Entrance Size Pee Circuits/Feeders Fee
0 fo 200 Amps 0 to 100 Amps
Above 200_Am s Above 100_Amps
MSPECTOR'S USE ONLV TOTAL �/ ��
'�"���..,. ti_���"�`
copy
Invesligafive iee - //' " � -
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLV This requesl mid�monihsl�om validafion do�e printed in this box.
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*❑ B 0 2 3 6 6 5 s '�/(
PLEASE PRINT OR TVPE �� � N` S/O
Reques� DaJ�e Roughin inspection required? �Yes ❑ No Inspecnon O�her Thon Raugh�ln: ❑ Ready Now Will Call
/ 0 �8 � I�oa m�n coll ihe inspxror when ready� Doie Ready:
I, ❑ licensed confrocfor �owner hereby requesf inspeclion of the above elecirical work af:
lob Addre:s �Slreei, Bax, o� Roure Na.) p P
� 20 NL GC NL pL. ry�r2/DCL--y ziS,�c���
To r�nr S e�
p6er
xc�� �,v��e�y
r?P�5
ynlo ICA
�e No.
763-5��-h�73
Lic. No-
"' 9 � Phone No.
�. Z63-571-6173
BOABO COPY - SEE INSTRUCTIONS ON BACK OF VELLOW COPV