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P - 84490/� REQUEST FOR ELE RICAL INSPECTION �1, 3�:� 2 g 1 Minnesota State Boar Electricity l� . 1821 Universiiy Av , Rm. S-128, St. Paul, MN 55104 Phone (612) gpp ome Duplex Apt. Bldg. Oiher: ... � Commercial Industrial farm New Air Cond. Ht E ui Remod 9• q p• Water Hfr. 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 bcrck of the white copy � Calculaie Inspection Fee - This Inspi Other Fee Mobile Home Park Stall Street Ltg./Traffic Sig. Transformer/Generator Sign/Outline Ltg. Xfmr. Alarm/Remote Conhol Swimmina Pool �obe�r'� '� `7� 7f�� n Request will not be accepted wiihout ►he correct fee: # Service Entrance Size Fee # Circuits/Feeders Fee 0 to 200 Amps 0 to 100 Amps Above 200 Am s Above 100 Amps INSPECTOR'S USE ONLY TOT/4� � . So hereby certify thaf I inspeded fhe elechical insfallation described herein on ff�e dates sfated D L Investigative fee F'"°I THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WI IN 18 MONT S. OFFICE USE ONLY This request void 18 months 6om validation date printed in this box. � �� I�IIIIIIIIIIII��IIIII �� III II ►�� II II III II II IIIIII � * 0 4 3 5 2 9 1 p� �� PLEASE PRINT OR TYPE Request Date `�` Rough-in inspection required2 ❑ y� o Ins fion Olher Than Rou Mn: � 9 ❑ Ready Now Will Ca�l (You must call the inspector when ready) Date Ready: I, licensed conhactor ❑ owner hereby request inspection of the above elechical work at: Job Address (Sheet, Box, or Roufe No.) Ciy Zip Code . /V C �" ` 1 ��c� �on No. Township Name or No. Range No. Fire No. ��,.w, _ � Occupant � %%� t1�2 �'r� Power $uoolier � ��Yr'�Q�1�' Addreu �M � Fhone No. I MlYIl11 e � oi �� `� ,••~y ' �onn� � � � Ir STATE BppRD COPY - SEE INSTRUCT1pNS ON BACK OF YELLOW COPY � Lic.