P - 81318REQUEST FOR ELECTRICAL INSPECTION �"�'
6/� �� (] O(] Minnesota S[ate Board of ElectriciTy �!
�F 7 �7 1821 University Ave., Rm. S-128, S4 Paul, MN 55104
. Phone (612) 642-0800 _-�
, Home Duolex Aot. Blda. Other: New Addn
� Commerciol Induslriol Farm Remod Re
'r Co Hfg. Equip. Water Hfr. Lood Mgmt. Ofher:
Dryer Range Elec. Heot Temp. Service
"X" obove fhe work covered by �his requesG Enfer remarks in �his space ond on rhe back of the whife copy only.
1�C /1P�0/��errc�.,�'
Colculate Inspection Fee - This Inspec�ion Requesl will not be occepfed withou� lhe rorrec� fee:
Other Pee 8 Service Enhance Size Fee # Circuits/Feeders Fee
Mobile Home Park Siall 0 to 200 Amps 0 l0 100 Amps
StreeY LIg.JTrafflc Slg. A6ove 200_Amps Above 100_Amps
TronsformedGenerofor INSPECTOR'SUSEONLY � . TOTAL//' �
Alorm/Remofe Confrol �O�
Swimming Pool '+ I here6 cere �ha� I �ns cred �he elecincal �mnalla��on described here�n on ihe dares,iared
Iffiga}ion Boom RwgMn Dote ..
$peciol Inspecfion
Fiml D
Investiga�ive fee �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
I� II III II ��I I��II II �II II I� II�I II III I II� OFFICE USE ONLY This reqms� vdd 18 mon�hs fr�� daf��
* 0 6 4 6 9 0 9 2 x �70. S°�
PLEASE PRINT OR TYPE
j%f� Ql� RcugMn inspecrion required? ❑ Yes [] No Inspecrion Other Than Rough-In: �d � Will Cc
��l � (Vw m�.� mll �he tn:pecmr when ready� Dare Ready. �� 9�
��b�f
�licensed coniractor ❑ owner hereby �equesl inspection of ihe obove electrical work ot:
Addresz �Sne Bw, Roule No.l Gy Zip Code
�3 5�' �ev� �u�� /Jr � �rCtl�
n n N. iownshio Name or No. R..��o Nn F�.o nb. r,... �
S � N_Ul
y _ cU3�
unmi mnw ��ompany rmme� Commnor License No. Mashr Lic.
Spaxk �Xec.t�C�.c caa1700
Mailing Address (Conhacror or Ovmer Perlormiig InsMllation�
2114 Wcr.sh.i.ng.ion S�c.e. � :.%
Aotha�ed 5' naNre ( cta ar Owner Padwming Inyollofion� Phone Na.
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� 8�96 S E B011PD COPV - SEE INSTRUCTIONS ON BACK