P - 83321t
532-532 �
Commercial
Air Cond.
Dryer
"X" above the H
Indushiol
Calculate Inspecfion Fee - This Inspe
Other Fee
Mobile Home Park Stall
Street Ltg./Traffic Sig.
Transformer/Generator
$ign/Oudine Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Rool
Irriaation Boom
REQUEST FOR ELECTRICAL INSPECTION —
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642 � SO e ,�
,v'.
Apt. Bldg. Other: '� New Addn
Farm Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in lhis space and on the back of the white copy only.
m Request will not be accepted without fhe correcF fee:
# Service Errtrance Size Fee # Circuits/Feeders Fee
0 to 200 Amps 0 to 100 Amps
Above 200 Am s Above 100 Amps
INSPECTOR'S USE ONLY TOTAL � `S�
vl�
that I insoec�ed the eleclrical installation described herein on the dates stofed
THIS INSTALLATION MAY BE ORDERED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE UsE ONLY This nqueaf void 18 months from wlidafion date prinled in this box
III�IIIIIIIIIIIIIII1111111�INIIIIIIIIIiiilllllll • ���
* � 5 3 2 5 3 2 9* pLEASE PRINT OR TYPE �� /�
Req�esf Da�e Rou I�in ins fion r uired$ ❑ Yes
g pec eq ❑ No Inspection Olher Than RougMn: ❑ Ready Now ❑�II Call
`D 4��� �� (You must call the inspecror when ready) Da�e Ready: �
I, ❑ licensed contracror � owner hereby request inspecfion of the above electrical work at:
lob Address �Street, Box, Route No.) Ciy Zip Code
�ps�i� �7�/�� �-2�rx�-`" �-�(.3�-
Secfion No. Township Name or No. Range No. Fire No. Counly �
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Elechiml Conhacior ICo�mauv Namel . Contrator lir�n�n N�_ M�.wY l;r._ No_ IPlant Eleci. Onlvl
Mailing Addreu (Conhacior . er Performing Installafion)
V
Au ignature (Conhacfor Owner Pe i Installafion) „� 1� : Q Pho�re No.
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B-00001,411 8/96 $7ATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY