P - 82056�i�2m189 �
Home Duplex
Commerciol Industri
Air Cond. Htg. Ec
Dryer Range
"X" above the work covered
Calculafe Inspection Fee - This Inspe
Other Fee
Mobile Home Park Stall
Street Ltg./TraFfic Sig.
Transformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
REC�UEST FOR ELECTRICAL INSPECTION ��°
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 -
Phone (612) 642-0800 `�'
Apt. Bldg. Other: t S. � New Addn
Farm j� Remod e air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in ihis space and on the back of ihe whi►e copy only.
m Request will not be accepted without the correc► fee:
# Service Entrance 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�I ��
OC
� �c'���0.�2 _� (
� �'�Y—!/—/—o�! r�
Special Inspection
Investigative Fee �--'-1 �� � r
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN ONTHS.
OFFICE USE ONLY This request void 18 months 6om validation date printed in this box.
IIIIIIIIIiilillflllllllllllill�ll��l�l�i ���� �
* 0 8 0 2 1 8 9 1 * a�,37
PLEASE PRINT OR TYPE
Requesf Daye( �� � 1� Rough-in inspecfion required? ❑ Yes ❑ No InspecFion Other Than RougMn: ❑ Ready Now ❑ Will Call
'L'� V (You must call the inspector when ready� Date Ready:
�
l, ❑ licensed conhactor �owner hereby request inspection of the above electricol work at:
Job Addreu �Sheef, Box, or Route No.) City Zip Code
�� �1��Cv�.9'�' �� �rr��� S.S'�32
Secfion No. Township Name or No. Range No. Fire No. Counly
,3a � y �.,er��
Oaupant Phone No.
�s.� ��'-�'%,. PlU < <,'�� .S ? �-O "� � �
Power Supplier Address
ns +�? 7� � ",�, �S. no,-� .n,�;S�a,
Eleckical Conhacbr �Company Name� Conhactor License No. Masler Lic. No. (Plant Elect. Only)
� N9 �t'/` ._
Mailing Address (ConfracTOr or Owner Performing Installation)
� R, w�
Authorized Signature �Confracbr or Owner Performing Insfallafion) Phone No.
LS��•2- �'� S�l-o'� t 1
EB-00001 A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY