P - 80841�2�6-180 �
RE(1UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
�`
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod
Air Cond. 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.
�-r ����if-� � �� S-�S,�l�- 6 ��Of� ��
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Ai
Transformer/Generafor INSPECTOR'S USE ONLY TOT,
ie Ltg. Xfmr.
iote Confrol
POO� - I hereb certi fhaf I ins ected fhe electrical insfallation
� Rouglrin
dates siafed
Fee
r�J
- - F��ai G
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WI HIN 18 MONTHS.
__. __ OFFICE USE ONLY This request void 18 months from validation dafe prinfed in fhis box.
iiifiiiiil�iiiiliiiiiiiiiiii��i����� • �-�
* 0 8 2 6 1 8 0 2* �Ct�7
PLEASE PRINT OR TYPE
Requeet Date Rough-in inspecfion required$ ❑ Yes No Inspection 011ier Than Rou h-In:
� g ❑ Ready Now Will Call
�/ Q (You must call the inspeclor when ready) Dafe Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Street, Box, or Route No.) Ciy Zip Code
d /(le,�r� �.c �iZl��
Sechon No. Township Name or No. Range No. Fire No. Counfy
Power
�
(Company Name�
No.
��.FL�/�il/�' F�'-�i%�-�CJ /3 ��
or Owner Performing Insfallation� �
!�-.�.� i/�-�cJ �
cfor or r Performing Installafion, �,� 4 8 5 P
�
STATE BO D COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
Lic.