P - 82788„ �
��4-�28 �
Commercial
Air Cond.
Dryer
"X” above the �
Duplex
Industrial
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 '' '
Other: t \ � New Addn
Farm
Water Htr.
Elec. Heat
request. Enter
' e h�t 1 7' O� GG Kemod
Mgmt. Other:
$ervice
in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 00 Amps " 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Amps
Transformer�Generator INSPECTOR'S USE ONLY TOZTAL�
Sign/Outline Ltg. Xfmr. /� d0
Alarm/Remote Control /
Swimming Pool
I hereb certi that I ins the elechical ' tallafion described herein on the dates sta�ed
Irrigation Bo RougMn D
Speciallnsp i
Final
Investigative Fee '
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 ONTHS.
OFFICE USE ONLY This request void 18 months 6om validation date prinfed in this box.
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* 0 6 5 4 6 2 8 7* `���7
PLEASE PRINT OR TYPE
Requesf Date Rou h-in ins on r uired$ �'res pec ug ❑ Ready N ill Call
g pecfi eq ❑ No Ins tion O�er Than Ro Mn:
7�.. ��Q �'(ou musf call the inspecfor when ready) Dafe Ready:
I, �censed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Street, Box, or Route No.) City � Zip Code
S.5a ,' � 5fi, l�J � ,� �� .y'�5'Y 3
Seciion No. Township Name w No. Range No. Fire No. ou�y �
�!2 b Gr�
ipplier
/V J
_�s
�Contracror or Owner F
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STATE
Phone No.
�,
Ad re s
O r�
Contractor License No. Ma ter Lic.
t co I�t � 4 D( g 3
3 lnstallafion��
�e
rmi sfallation � Phone No.
�
4R - SEE INSTRUCTIONS ON BACK OF YELLOW OPY
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