P - 81223� RE(�UEST FOR ELECTRICAL INSPECTION ��W =...
8 j�-16 7 � Minnesota State Board of Electricity a
1821 University Ave., Rm. S-128, St. Paul, MN 55104 -
Phone (612) 642-0 0 "�'
Home Duplex Apt. Bldg. Othe�:0 New Addn
Commercial Industrial Farm ' a�� Remod Re air
Air Cond. 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.
Calculate Inspection Fee - This Inspection Reqvest will not be accepted without ►he correct fee:
Other Fee # Service E rance Size ee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 20 A 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transfo�merjGenerator n�SPeCroR's usE oN�v TOT���
Siqn/Oudine Lta. Xfmr. •
Swimming Pool
I hereb certi that I ins the electrical 'nstallation described herein on the dares slated
Irngahon Boom RouqMn A. � %� � Dar�Ji
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MON7HS.
OFFICE USE ONLY This request wid 18 monfhs from validafion dafe prinfed in ihis box.
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PLEASE PRINT OR TYPE
Requesf Date Rouglfin inspection required2 ❑ Yes ��o Inspecfion Other Than RougMn: ❑ Ready Now � Will Coll
�% �%��- 9' 9 (You musf call Il�e inspeclor when ready� Dafe Ready:
I, � licensed conhacror �','owner hereby request inspection of the above electrical work ah
Job Addreu �Street, Box, or Route No.) Ciy F�) A �- Zip Code
�LC3 �,�v sj- rv �c.�• �:�..r� !i�°� 55'yZ/
Seclion No. Township Name or No. Range No. fire No. Couny
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Occu nf phone No.
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Power Supplier � Address
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Elech�ical Conhaclor (Company Name) Conhacfor License No. Masfer Lic. No. (Planf Elecf. Only)
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� Mailing Address (Conhacror or Owner Performing Insfallafion)
Sa rr� �
� Signature �Conhacfor or Owner Performing Insfalkrtion�� f�J� r Phone No. ^ u�
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�-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY