P - 81008REt�UEST FOR ELECTRICAL INSPECTION �
8(� �'j �� C Q � Minnesota State Board of Electricity �
�S� L J V 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 air
Air Cond. Htg. Equip. Water Htr. Load M mt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy oniy.
Calculate Inspection Fee - This Inspection Request will rot be accepfed without 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. f Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ON Y n TOTAL,�! �6
Sign/Outline Ltg. Xfmr. �j''Lt,�,c.e� l�C��� �r
Alarm/Remote Control %�'+Z o �4 -� � ��«�'e- �''�� .
Glit Ga�.'�
$Wimm� � I herebvi certifv that I ins � the eleclrical installation described herein on the dafes stated
Investigafive Fee / l�"�
7HIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
.. OFFICE USE OIiLY ihis request void 18 months (rom validafion date printed in this box.
IIIIIIIIIIIIIIIIIIIIIINilllli�lllin f �a���� 5��
�I I�I ��
* 0 8 0 2 1 5 8 6*
LEASE PRINT OR TYPE
Request te Rough-in inspecfion required$ ❑ Yes No Inspecfion Other Than Rouglrin: ❑ Ready Now Will Call
o q g �`(ou must call �e inspector when ready) Dote Ready:
I, ❑ licensed contractor �owner hereby request inspection of the above elechical work at:
Job Address (Skeet, Box, or Route No.) Ciy Zip Cade
.r�c,r oN T nr �e �,�zE'
Section No. Township Name a No. Range No. Fire No. Counfy
3o a w� �tcs�
Occupant Phone No.
RA-�� �T_ �'u�w� �.F G �� -7 3 � is-s-�
Power Supplier Address . �
S i� /`I l� < �Q r�s ! t/,
Eleckical Conhactor (Company Name� �. Conhador License No. Master Lic. No. �Pbnt Elect. Onfy)
N
Mailing Address (Conhacror or Owner Performing Insrollation) �' �
�E `�4:�
Authorized Signature (Conhacfor or Owner Performing Installation) Phone No.
�.wso�) /.� — % 83 —/ i S a�—
E&00001 A- 1 8/96 STATE BOARD COPY - SEE INSTRUCT{ONS ON BACK OF YELLOW COPY