P - 813087�'�°299 �
REQUES7 FOR ELECTRICAL INSPECTION ¢� ��u�u� I
Minnesota State Board of Electricity
1621 University Ave., Rm. 5-128, St. Paul, MN 55104
Phone (612) 642-0800 �:�
. Ofher: New �d�
Form
Water Hfr. Load Mgml. Other:
Elec. Heot Temp. Service
requesG En�er remarks in /his space and on
copy
�b C��.L�� 1�51-Z�'i-�1��5
Calcufo/e lnspec�ion Fee - ihis Inspection Reques� will not be accepted withou� the mrrect fee: �
O[her Fee # Service Entrance Size Fee M Circuifs/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 1�0 -
Streel Ltg./Tmffic Sig. Above 200_ Amps Above 100—� Amps �
Transformer/Genemror INSPECTOR'S USE ONLY TOTAL
�e �,�. xr��.
iote Conrrol
Pool
herein on �he do�es siated
�OI I
Investigative Fee F���� `/--�`""�--� =�— �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMP�ETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void I B monihs from wlidalion dare prinled in �hls 6ox.
������I�����������������������I�III������I � �G-�
* 0 7 7 5 2 9 9 I, x ��(9
PLEASE PRINT OR TYPE
Request Da�e Rough�in inspecticn required? (] Yes o lospecrion Other Thon Rough�ln: ❑ Reody Now ill Call
5�� a. — �You m�n mll �he Inspecror when �eody� Do1e Reody:
I, � licensed coNmctor � owner hereby requesf inspecfion o( the above elecfrical work at:
bb Address �Srceei, Box, ar Roo�e No.� Ciry Zip Code
�5D ,�SS'�.r�2 lx. F�-i�1�.+'f `,=F ��
Seclion No. Town:hip Name or No. Range Na Fire Na. CounN
Occu
��.l1'�2
Pwver Sopplier
Ele triml Connocror �Canpi
BWNEH
Moiling Addreu
C
ELECT., INC.
i-
Master
�
___.___ . ___ ,_ ._ ....�. ����„�y��y ���.�������o�� Pha No.
7�'�1 �e
� �l 5� -(D
EB00001A 8/96 ����,��COPV-_SEEINSiBUCT10N5ONBACKOF.YELLOWCWY