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REQUEST FOR ELECTRICAL INSPECTION
� Minnesota State Board of Electricity� `3
1821 University Ave., Rm. S-128, St. Paul, �N 55104
Phone (612) 642-0800 "�°`
iplex Apt. Bldg. Other. �� New Addn
Calcula►e Inspectio 1
Other
Mobile Home Park Stail
Street Ltq./Traf{ic Siq.
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irriaation Boom
Farm Remod
Water Htr, Lood Mgmt. Other:
Elec. Heaf Temp. Service
request. Enter remarks in this space and on the back of the whi►e copy
�Yrfsp'ection Request will not be accepted without fhe correci fee:
Fee # Service Entrance Size Fee # Circuits/Feeders
0 to 200 Amps 0 to 100 Amps
Above 200 Am s Above 100 Amp:
INSPECTOR'S USE ONLY TOTAL
� ��r,�c �y C� �ii -C /lZ.e� 7�3 ' .
! herebvi certifv dwt I insuecFed 1he�leclrical installation described herein on the
F�
'9
� Investigative Fee � �.� ( ��'��� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WIT IN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date prinfed in this box.
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* 0 8 0 2 3 3 8 4* � 1�
PLEASE PRINT OR TYPE
Request Date Rou h-in ins tion r uired? Yes
/� g pec eq [� ❑ No Inspection Other Than RougMn: ❑ Ready Now �Will Call
g"�—(„/ � �You must call the inspector when ready) Dafe Ready:
I, ❑ licensed contractor [� owner hereby request inspection of the above elecfrical work at:
1ob Address (Slreet, 8ox, or Roufe N � r� Ciy Zip Code
� y � � (�Z � 0 � 1� ( �r I c.� � � S `�-3�
Section No. Township Name a NQ, Range No. , Fire No. Couny
o«opo�r
P�,e�
Mailing Address (Conhador or
�y� s'kle�
�ri
�
�4�01
Phone No.
763-�85- �o�
� /�
license No. Masrer Lic. No. IPlant E
fr; �1 ,S�S�y3�Z..
Phone No.
763>>�s—�c��
TRUCTIONS ON BACK OF YELLOW COPY