P - 81003� �"')� REQUEST FOR ELECTRICAL INSPECTION
6��- 91_ 1�� + 1n821eUniversity A earRm. S-128,ISt. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other:
Commerciai Industrial Farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:C�
Dryer Range Elec. Heat Temp. $ervice •J�� �
"X" above the work covered by this request. Enfer remarks in ihis space and on the back
Calculate Inspection Fee - This Inspection Reques► will not be
Other Fee # Service Entrance
Mobile Home Park Stall 0 to 200 Ampsr
Street Ltg./TrafFic Sig. Above 200
Transformer/Generator iNSPECTOR'S USE ONLY
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
1 herebvi certi(v ihat I insoetfe
New
copy
without the correct fee:
=ee Circuits/Feeders
0 to 100 Amps
Above 100 Ai
��
the electi wl installation described hersin on the d�sta�
._:,r: DateiL��2 /�
� Investigative Fee j` " �` � /(/.�!' /
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This raquest void 18 months from validation date prinfed in this box.
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PLEASE PRINT OR TYP ��� �
Requesf Dafe� � Rough-in inspecfion rec{uired? Yes ❑ No Inspecfion Olher Than RougMn: Ready Now ❑ Will Call
Q ^� (You musf call fhe inspeclor wh dy) Dafe Ready:
I, licensed contractor ❑ owner hereby request inspection of the above elechical work at:
lob Addreu (Sfr x, or Route No.� Ci Zip Code
, � 5b �t3a
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Section No. Towns ip Name or No. . Range No. Fire No. y
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n 1r �.. .,., �u., c�(�,S � �i `" �� (o'l.�
Power $upplier _ , . Address � .
or Owner
:d Siqnature ( actor or
Conhacror License No. Master Lic. No. �Plant Elecf.
��: �. � G�v'�6o3
oiiana�► �
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� Installation) � �g�J� ��
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COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY