P - 80897'6?�-737 �
Indus�rial
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electriciry
1821 UniversiTy Ave., Rm. 5-128, St. Paul, MN 55104
Phone (672) 642-0800 �
Apt. Bldg. Other. i
Form aru � � Re
Water Hlr. Locd Mgmt Other
"X" above Ihe work covered by this requesG Ertter remarks in this space and on ihe back ot Nie whil
io l�. � C-Q t�c� `f -I 1—"1 F Sr �
Calculate Inspection Fee - ihis Inspecfion Request will not be occepted withw� the mrrect fee:
O[her Fee # Service Enhance Size Fee # Circuits/Peedi
Mobile Home Park Stall 0 fo 200 Amps r 0 to 100 Amps
Sfreel Lfp./TraHic Sig. Above 200—Amps Above 100_
INSPECTOF'S USE ONLY
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<opy only.
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dales sMled
�Investigative Fee �— — �� �� �' � (
THIS INSTALIATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MON
OFFICE USE ONLY This request void 18 monihs fmm volidmion dafe prinled in ihis 6ox.
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PLEA5E PRINT OR TYPE
Requax� Do�� � �� gough�in inspection required2 ❑ Yes Inspeclion Olhe� ihon Roughlm ❑ Ready Naw Will Coll
b� �Yo� m�s� coll ihe inspecror when reody) Date Ready:
I, [�icynsed conlmcfor ❑ owner hereby requesf inspecfion of ihe above eleclriml work af:
Job Address �Sneep eoz, ar Raire No.� Ci� / Zip Code` /
+ya�r M�SSiSSiQ(�� $� �-r:cJ�tS/ 2`i73Z
Occ�pa�" \
�"\0.v-Sl.�.er �'t � rc.
Power Supplier pddress
+1 a i��_
-S71—g/.��
tlechical Canhpclor �Co y Name) Canhacbr Licens¢ No. hbsler Uc N¢ �Pknt Eler.f. Qdy)
Sotn��� ��,w..�ati F<<L �'!4o I6`1 (�
Moiling Address �Canrcacror or Owner Per ming Insmll tion�
�'� a 3 c� ►� k�. �� �- �v e S 5"s�3 z
Au�horized Signorore (Conhacbr or Owner Performi� Insm"llaR"On� Phone No.
/`'� e�a.�.� `� � io l 7� F 1�_�� Y b
EBDOOOIA-11 8/96 STATE BOARD COPY - SEE INSTRUCT10N5 ON BACK OF YELLOW COPY