P - 80678,
I�lI�II IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIII IIII
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REQUEST FOR ELECTRICAL WSPECTION ��
Minnesota State Board of Electricity � °'
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 Repair
ir Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this request. Enter remarks in this space and on the back of the white copy only.
/�G� l..Y (..�C� � ����_.._
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee s� Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traftic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA� �
.
Sign/Outline Ltg. Xfmr. ����
Alarm/Remote ContcoP�
Swifl'lhllflg POOf �`� I hereby certiry that I inspected the electrical installation described herein on the dates stated
II"1'IgZt1011 BOOfTI ,�� '>" Rough-In Date
Speciallnspecti �'
Final Datef
Investigative Fee �- Z �—G
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MOFITHS.
�- _-._�__�...__-------___ — _ _--r--
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
396-208 [� • �o. �
,�td'�a
PLEASE PRINT OR TYPE
Request Date � Rough-in inspection required? ❑ Yes No Inspection Other Than Rough-Ir�� R dy Now ❑ WII Call
(You must call the inspector when ready) Date Ready: �OL
I, �, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �reet, �oute No.) �� �� City p, �� Zip Code
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Section No. Township Name or No. Range No. Fire No. County
Occ nt � Phone No�� ' �70 �
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Power Suppli Address
EI rical Contractor (Compa N me) ' Contract r License No. Master Lic. No. (Plant Elect. Only)
� t `/
M�'n�ddres (Contractor. or�Performing Installation) ., /`� G�.-
( /l./ �
Autho 'zed , igna e(Cor�ractor or Owner forming Install w� Phone No.
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EB-OOOOtA-11 8/95 S TE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY