P - 83326705�-265 �
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Home Duplex
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity �
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �'��
Phone(612)642-0800
Other: New Addn
Commercial Industrial Farm Remod Re air
Air C n. Htg. Equip. Water Htr. Load Mgmt. 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 only.
p.,�b C�+ a►�v� ���-��$s
Calculaie Inspection fee - This Inspection Request will nof be accepted wiihout the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
$treet Ltg./TrafFic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL L
Sign/Outline Ltg. Xfmr. � � � �7�
Alarm/Remote Control
Swimming Pool
I hereb certi fhat I ins ed the electrical installaHon described herein on fhe dates sfaled
IrrigOtion Boom Rough-In Date
Special Insp
Investigative F1O°I Dare , .Z � __Q
TPiIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validafion dafe prinfed in fhis k�ox.
IN��II��INI�I�I�I���I��I�II�fI�IN�����! • ��a�
* 0 7 0 5 2 6 5 7* /��7J
PLEASE PRINT OR TYPE
Request te Rough-in inspecfion required$ ❑ Yes No Inspeciion O�er Than RougMn: ❑ Ready Now � Will Call
u� a� $ (You must call the inspector when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrica! work at:
Job A ress �Sheet, Box, or Roufe o. City Zip Code
s�- I�.e. lc�.�. �5�'�2-
$eclion No. Township Name or No. Range No. Fire No. County
Occupanf � Phone No.
O�M cj� l - SSS`b
Power Sunolier Address
Elechical Confracfor (Company Name)
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Mailing Add i � Ilat
. ANOKA��04
No.
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STATE BOAAD COPY - SEE 1NSTRUCTIONS ON BACK OF YELLOW COPY
Lic. No.