P - 81342J III�II II III I(IIIII II IIII I II � REQUEST FOR ELECTRICAL WSPECTION .���
Minnesota State Board of Electricity � �_
1821 University Ave., Rm. 5-128, St. Paul, MN 55104 ����
� * 0 3 9 2 4 0 0 8* Pnone �siz� saz-oeoo
Home Duplex Apt. Bldg. Other: New Addn
Htr. ;< Load Mgmt. Other;
leat emp. Service
rler remarks in Ihis space and on (he back o/ Ihe whi[e copy wrly.
_�A'v' i' .. _'F I.TCi, ii��. ,"A:.._i�T `.. �;i
Calwlafe Inspection Fee - 7his Inspectiwr Request will not be acceptetl without the covecf /ee�
Other Fee � Service Entronce Size Fee n Circuits/Feetlers Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200_Amps Above 100_Amps
Transformer/Generator INSPECTOR'S USE ONLV TOTAL!
Sian/Outline Lta. Xfmr. �ST. `_�P�-
�J �iYI� I he�eby certify �ha� I Inspeqtetl me eleGrical melallafion tlesaribed hereln on �he tletes t,1aG
BOORI Rougp-In � �ate
ispection
:ive Fee ' ,, _:��: r,��� �__��.(.✓s— � V% /lc–
THIS INSTALLATION MAY BE ORDERED� DISCONNECTED IF NOT COMPLETED WITMN 18 MONTNS. �
OFFICE USE ONLV This request witl 18 monihs from valitlation tlate printed In �his box.
392-400�] �� �
JCIS HUP?Y€_R k_�ii�_� t<'�:n
PLEASE PRINT OR TYPE
Reque{Y Date,.� ���� . qougn-in inspection required? p Yes p�lo Inspao�lcn Olner man Rouoh-Irt. pS Reedy Now p wN Call
lf
(YOU must call the irispector whan reatl9l �ate Reatly: —,�
. � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Atldres: (SVeet, BaK or Route NoJ Clly Zlp Gode
07 ��3� LYRIC Lh NE FkIi7LEY �_�543<
Section No. Township Name w No. Range Nn Fire No. County
ANOF:A
Occupan[ Phone No.
V,;[3A i1AK�'c: GC'.; "3V -;?i4�:�
Power Suppller Address i
Fd�P Me'L.`i. OHFT_GE
Electrical ConVactor (GOmpeny Neme) Contracror Llcsnss Na Master Llc. No. (Plent Eleat Onry)
MA3TLft E�EC.Th s.;� GC;. ,."�;�i�-:;. CAt�f..' -
Mailing Atltlress (GOriVector or Owr�er Perlorming Installallon�
i�467 BOL3Ne: AVE '� '=.AVAIiE ,"C�l. �`�37E'.
Aulhonzed Signature hactor or Owner Periorming InstvlaGOnj Phone No-
2 f-7 �
E&00001A-11 8/95 STATE BOAR� COPV - SEE INSTRUCTIONS ON BHCK OF VELLOW COPV � �