P - 81322625-954 �
:r
REQUEST FOR ELECTRICAL INSPECTION §"
Minnesota State Board of Electriciry
1821 University Ave., Rm. S-728, St. Paul, MN 55104
Phone (612) 642-0800
Com�nerciol Industrial Form Remod Re
Air Cond. Hfg. Equip. Wofer Hfr. Lood Mgmt. Other:
Dryer Ronge Elec. Heat Temp. Service
"X" above the work covered by fhis request Enfer remarks in fhis spoce and on the back of the w6ife copy only.
`Te/ � � n t w /�Z
Cakulate Inspecfion Fee - This Inspec/ion Request wifl not be accepted wifhou� the mvect (ee:
Other Fee # Service Enlmnce Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 fo 100 Amps
Streel L�g./Traffi<Sig. Above 200_Amps Above 100_Amps
Transformer/Genemtor INSPECTOR'S USE ONLV TOTAL
$ign/Oufline L�g. XFmr. ti�• S�
Alorm/Remote Conhol
Swimming Pool i he�eb �e�r; �hm i mrpe�ied rhe el�m�al msmnaro� de:�r�bed he,em o� �he da�e::m�d
Iffigafion Boom Raughln Date
Speciallnspectio " �
. Fmol � Dafy- � �_ CJ
Investigafive Fee C
THIS INSi�J,�ZJON MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WI7HIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monlfis hom valldoFon dare printed in Iliix 6ax.
���III��� I�U�����I��IN�MI�������U��uu � a� _�
* 0 6 2 5 9 5 4 3* 3r°Z�
PLEASE PRINT OR TYPE �
Raques� Dole RwghJn'mspecfian reqoired2 o inspecfion O�er Than Rwigh�ln: eody Now � Will Coll
s-r �- 95 I�o� mun coll �he inspe��w when reody� Dme Reody
I, �'I censed ronhacfoi ❑ owner hereby request inspection of Ihe above electrical work at:
lob A2drea �Streat, eox, w Roure No.) Ciy Z� ��
�oSS� /L1rn�o� S�if/,r �t,�1._ S'3'Y3.Z
3�rr ��rt,G�
Phone No
���
F�
� �y - �3S—G
� �r
� s— �,� �- /3G�,! /� s`�'
Auth ' Signo�ure �Cm�maor or Owner Pe ml�g Insmllofon)r, Phone No.
<_� �': j QC2 a-sG_
EB�OOOOIAI 7 8/96 STATE COPY - SEE INSTRUCTIONS ON BACK OF VELLOW COPY