P - 8065279���905 �
Home Duplex
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University AVe., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 '��
Other: New Addn
Commercial Industrial Farm ' Remod Re ai�
Air Con .� Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
�b C�o�u.� �s i -
-r,-r-� ��s
Calculate Inspection Fee - This Inspection Request will nof be accepted without the correct fee:
Other 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 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ON�Y TOTAL
Sign/Outline Ltg. Xfmr. � Q. S�
Alarm/Remote Control
Swimming Pool
I here certi thaf I ins �e elechical installalion described herein on the dales stafad
Irrigation B - Rough-In Dare
Speciallns o
. Final Da - � �
Irnestigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONT S.
OFFICE USE ONLY This roquast void 18 months (rom validation dafe printed in this box,
�IlI�I��Ill�lfl��lli�����ll��l�l���l�ill���l • �-�
* 0 7 9 9 9 0 5 5* ���3
PLEASE PRINT OR TYPE
Request Date Rou h-in ins ection re uired?
g p q ❑ Yes o Inspection Olher Than Rough-In: ❑ Ready Now ill Call �
��a—� �q (You must call fhe inspector when ready� Date Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electricol work ot:
Job Address (Sheet, Box, or Route No.) Ciy Zip Code
15t1 Ti�nl�e..rid l�2� �ridf-2 �s'43z
Section No. Township Name or No. Range No. Fire No. Counfy
�M' ` � Phone No.
� rc� lA-r�o,� .Q I�S�Y1 � �1 `1 ?�-� q q �
Power Supplier '
� Eleckical Conkacror (Compan N
cz� e�NIF HT�.�i,i: ELECT., iNC.
���.
��nsmnation� �� �
�7
erForm�g Insmllation) Phone No.
`7 5�-�7;vo
BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY