P - 83056' REQUEST FOR ELECTRICAL INSPECTION
�/� �� p�/� Minnesota State Board of Electriciry
4�' 0 �� 1821 University Ave., Rm. S-128, St. Paul, MN 55104 =
Phone (612) 642-0800 '��
ome Duplex Apt. Bldg. Other: New ddn
Commercial Industrial Farm Remod Re air
Air Htg. Equip. Water Hir. Load Mgmt. Other.
Dryer Range Elec. Heot Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size fee # Circuits/Feeders Fee
Mobile Home Park Stal{ 0 to 200 Amps to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 1 W Amps
Transformer/Generator INSPECTOR�s use oN�v TOTAL r,
Sign/Outline Ltg. Xfmr. S •��
Alarm/Remote Control
Swimming Pool
I hereb certi Ihaf I in the eleclricol installation described herein o� fhe dales slaled
Irrigation B •- RougMn Dale
Special Ins i • .�
Final
Investigative Fee ` 2 � ^-QC�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
. OFFICE USE ONLY This requesf void 18 kom validafion date printed in this box.
I�II�IIIIIIIIIIIIII �I�III��I���I� l��
* 0 6 4 6 8 9 4�� ��1�
PLEASE PRINT OR TYPE
Requesf Dote � �� Rough-in inspeclion required2 ❑ yes�� Inspection O�er Than Rough-1�: Now � Will Call
(You musf call the inspecfw when ready) Dale Ready:
I,�ensed contractor ❑ owner hereby request inspection of ihe above electrical work at:
Job Addreu �Skeef, Box, r R .) � Ci - Zi Code
S� 3��su r�� P� S7- ��,� � cQ S��3 �.
Sec�ion No. Township Name or No. Ronge No. Fire No. County
C�� v�caJ
Occupant Phone No.
M �83- �a �
Power suool'ie� nad.a�.
�I Conhac�w (Company Name� Conhactor License No. Master Gc. No. (Planl
$rJ6VtFt ��2C�'li.(.0 CQO l %OO
i Addreu (Confracfor or Owner PerForming Installation) .
2114 Gla�sFc.i.v�g�an S� N.e. . �
zed Si natur n aclor or Owner Performing Insfa fi i� ;� Phone No.
����.C.e/t 781-6200
ilA-I 1 8/96 STATE D COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY