P - 77863`., REQUEST FOR ELECTRICAL INSPECTION ,�.:�, Ee-0000�_e�
�N,��777 � �' ``-
See instructions for completing this form on back of yellow copy.
"X' elow Work Covered by This Request
Ne Add Rep. Type of Building Appliances Wired Equipment Wired
Home Range Temporary Service
Duplex Water Heater Lightiny Fixtures
Apt. Bui Iding Dryer Electric Heatin
Commercial Bldg. Fumace Silo Unloader
Industrial Bldg. Air Conditioner Bulk Milk Tank
Farm Other SpecifV OtherlSpecify)
t er Specify Other Other
Compute /nspection Fee Below
N Fee ServiceEntranceSize t! Fee Feeders�Subfeeders ft Fee Circuits
Oto100Am s Oto30Am s Oto30Am s
101 to 200 Amps 31 to l OQ Amps 31 to 100 Am s
Above 200 Amps Above 100_Amps Above 100_Amps
Transformers Remote Control Circ. Partial�'Other Fee
Signs Special Inspection 5����,.1 TOTAL FEE
Remarks � j/ j% ��'• �� ( p ( �
(��t�' r�/ C��� �
Rough-in ��/� Date I, the Electrical
}��
V Inspector, hereby
ertify that the above
Final -� / Date inspection has been
'`� � t—'�'1'l,l � � - �Z made.
This request void
18 months from �
�---------- __ . , —� _ _ _ - —
This reques[ void � ^�O �
18 months from �
7 �. 1�� rb �--^�
Reques e Fire No. Rough-in n ction
Require � eady Now Q.AMrf�Notify, Inspec-
� es [or When Ready
. License lectrical Contractor I hereby request inspection of above
❑ Owner . electrical work installed at:
Street Address, Box or Route No. City
'' `C G S /Ir / � E
ecuon o. Township Name or No. Range No. County
� �. Nc� �
� Occupant (PRINT) � Phon�o. ���� �
Power Supplier Address
� �'Q s_
Electrical Contracior (Company Name) Contractor's License No,'
� �� � �' � � fi�� a �'
Mailing Ad�iress (Contractor or Owner Making Instailation)
� /� e� �l� � �7`%
Authorized Sign�,ture (C )ractor/O r Making Installationl hone Number �
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THIS INSPECTION REQUEST WILL NOT
MINNESOTA STATE BOARD OF ELECTRI BE ACCEPTED BY THE STATE BOARD
Griggs-Midwav Bldg. — Room N.191
UNLESS PROPER INSPECTION FEE IS
7821 University Ave., St. Paul, MN 55104
. _ Phona 16121 297-2111 _ ENCLOSED.