P - 83000�:J�-490
1\ Home
Commercial
Air Cond.
Dryer
"X" above the work
Calculate Inspection Fee - This Inspe
Other Fee
Mobile Home Park Stall
Street Ltg./Traffic Sig.
Transformer/Generator
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irriaallon Boom
REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S- 28, St. Paul, MN 55104 �
Phone(612)642-080 �
t
Apt. Bldg. Other: t-v New Addn
Farm S'' Remod Re air
Water Htr. Load Mgmt. Other.
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of the white copy only.
�n Request will not be accepied without the correct fee:
# Service Entrance Size Fee # Circuits/Feed�
0 to 200 Amps 0 to 100 Amps
Above 200 Am s Above 100
INSPECTOR'S USE ONLY � 3 ` T�
��3 f � �' c d�+'� /t�.u��
Fee
! . �l-�
the elechical installation described herein on the daAes stafed
�. _ G7 . / DO�/
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFiiCE ImE ONLY This requsst void 1 S � validafion date printed in this box.
IIIIIIIIIIIIIIIIIIIIIIII III�III�II�I� 3/ Sd
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* � 5 3 2 4 9 Q �* pLEASE PRINT OR TYPE
Reques Date� . Rou h-in i fion uiredg Yes
.� g nspec req ❑ No Inspeclion Olt�er Than RougMn: ❑ Ready Now � Will Call
�' (You must call the inspector when ready) Dale Ready:
I, ❑ licensed conhactor Ld owner hereby request inspection of the above eleclrical work at:
Job Addreu (Sheet, Box, or Roule No.) Ciy Zip Code
�I.Z l�% D /�a SJtil.3Z—
Section No. Township Name o. Range No. Fire No. Couny
� � D�
ocn,pa�r Phone No.
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a
�rize
,
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W
W �(..�I l/
icior or Owner Performing Installafion�
�-�=�
STATE BOARD COPY - SEE
Con+radw License No. � Maste. l'K. No. (Plom E�et. onbl
I s� � - �vr�-1
OF YELLOW