P - 82739REGIUEST FOR ELECTRICAL INSPECTION w�..
c���� Q/� - Minnesota State Board of Electricity -
�J U'-t 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 ir
Air Cond. Htg. Equip. Water Hfr. Load Mgmt. Other:
Dryer Ran e Elec. Heat Temp. Service
"X" above the work co, vered by fhis request. Enter remarks in this space and on the back of the h{�e copy only.
�'/L�s � � `oo ,9�,�yo �G�.� � �,w�
�, s`�.,.�:� � l s� � �loa-,-
�
Calculate Inspection Fee - This Inspection Request will not be accepted withouf the 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 TOTA
Sign/Oudine Ltg. Xfmr:„ l�N a'Z°'�8
Alarm/Remote Confrol > ��y� � ��g9
Swimming Pool
1 hereb certi ihat I in the electrical insmllafion described herein on ihe da�es stared
Irrigafion Boo RougMn Dore
Special lns � p�
{nvestigative Fee G�—'" —�
THIS INSTALLATION MAY BE ORDERED CTED IF NOT COMPLETED WITHIN 18 MONT S.
OFPK� USE ONLY This requesf void 18 months from validafion dafe printed in this box.
, 55�
INIIIIIIIIIIIIIIII� IIIIIIIlIIIII
illl!!�!I �,
* O S 3 S 7 S� 3�K PLEASE PRINT OR TYPE
Requesf Rough-in inspecfion required$ ❑ Yes �No Inspeclion O�er Than RougMn: ❑ Ready N ill Call
�j �You must call the inspeclor when reody) Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above eleclrical work at:
Job Addreu (Street, Box, w Route No q
� ��� � � �����
Secbon No. Township Nome or o. . Ronge No. Fire No. ou
�D a� ' �
�.
S� e. S� 3_ c� I
Power Supplier � q��e
S Ls ����- .��r�
Eledricd Contracfor ( puny Nam-) � Contracfor Licenze No. Moster Lic. No. �Planf Eletf. Only) �
. � • � . C��� � y4'�^" D�'�%
�ing Address (C cfor or Owner Performing Insial ation)
V( Yl�� -�M, /�/`� �3.��
A Signoture �Conha r Ow r Per�rming Insfa�a¢on) Phone No. �
•`�1�. , ,�' �iFZ� ��S-S_
E 1 A-11 8/96 �p� �,�D COPY - SEE.lNSTRUCTIONg p41 BACK OF YELLOW COPY