P - 8141474 �-253 �
Home Duplex
RE�UEST FOR ELECTRICAL INSPECTION �� �,
Minnesota State Board of Elechiciry� p��
1ffi7 University Ave., Rm. S-128, St. Paul, MN 55104 ��'
Phone (612) 642-0800
Ofher: New Addn
� Elec. Heat � � Temp. Service �
requesG En�er remorks in this space and on
��C�W �JL�Li� �!�'��.��.e/!X� ��eGC// y
Calculate Inspection Fee - This Inspection Reques� will not be accepted wifhout fhe mrrec� fee:
Other fee # Service Entrance Size Fee S Cirwits/Feec
Mobile Home Park Stall 0 ro 200 Amps 0 ta 100 Amps
Slreet Lig./Tmffic Sic. Above 200_Am s Abave 100_
Transformer/Generafor INSPECTOR'S USE ONLV T
copy
iS,
Irrigafion Boom y po�gha� oare
$peciallnspecfi �
iinal Dm q
Imesfigative Fee ^ Zd—!
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
._� .--_ '—___—_— ____ —._ _.--. -- ___._----_—__.
' OFFICE OSE ONLY ihis requeslwid I�ths hom validatior. da�e primed in �his box.
INII IIII�II III III I�IIIIIIIIIIIII II �S,SC�
* 0 7 4 2 2 5 3 8� a3,�
PLEASE PRINT OR TYPE
ae �e.r o�e // ao�ye-�� ���.P«xa� ,eqd�.edz ❑ re. ❑ Na i�.���o� ahe, rno� ao�yha�: aeody Now O w�n cau
� �va� m�.r �ou rha ��s�«�o..�na� ,eady� oa�a a�dy:
I, icensed controctor ❑ owner hereby request inspection of �he above electricol work at
Jab Addrexs (Sreet, Box, or Ro No.� Ciy Zip Code
% �o �S .� %Z
Sxrion No. iownsh�p Name or No. Ranqe No. Rre No. Counm /1 i
n
naa�
l`L`�m`�`L��RIC.INC. `°"„°
S„ � w`��'$s�;�9��=�aua�o�� J �1
r�
re �Convanar or Own rming Ins�dlmim
6 STATE BOAP C PY - SEE INSTiIUCTONS
- 1s�8�
;.5� / C�