P - 80245REQUEST FOR ELECTRICAL INSPECTION
�_�c�7�Q_Q22 � Minnesota State Board of Electricity F:-
�•J v 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.e/ectricity.state.mn.us '. ° `'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Loa� Mgmt. Other:
Dryer Range Elect. Heat Temp. Service
'X" above the work covered by this request. Enter remarks in this space and on the back of the white copy on/y.
�
(N ✓ c..X� /��
�
Calcula e� Mspection Fee - This Inspection Request will not be acce ted withoui the correct fee.
Other Installations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
TransformedGenerator INSPECTOR'S USE ONLY TOTAL� ^�
Sign / Outline Ltg. Xfmr. ��lJ
Alarm/Remote Control
Swimming Pool
I hereby cert' that I inspected the electrical installation described herein on the dates stated:
Irrigation Bo Rough In Date
Speciallns i
PRial Date
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WI IN 18 MONTHS.
'M^��~�.���~���m���MmMM�MMmrt.^ OFFICE USE ONLY This request void 18 mondis from validation date printed in tliis box. ��
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIJIIIiGIIIINIiIII � a6 ��
*os5ss22o* J_��
PLEASE PRINT OR TYPE
Reque t Date Rou h-In ins ction re uired? ❑ Yes Na Ins
g pe q pection Other Than Rough-In: eady Now ❑ Will Call
You must call the inspector when r ady! Date Ready:
I,� licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Add (Street, Box„ r Route No. City Z��e: `
r .. T�
Section No. Township Name or No. Range No. • Fire No. County
nt � + Phone No.
�C�vtC� �- �r�rra �rr /.�'- �" 1�-- �/�-�
Power Supplier
EIeCNical Contractor !
pany o/r Own
�/'I41
Company or
� �
EB-OOOOtA-12 5/1999
(F� �
il--�'I / � 8 I ► /Yd� / b /� � �/GVl
BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY