P - 8469749��064 �
.�
Home Duplex
Commercial Indusfri
Air Cond. Hta. E<
W/Y
REQUEST FOR ELECTRICAL INSPECTION -
Minnesota State Board of Electricity
1821 Universiiy Ave., Rm. S-128, St. Paul, MN'55104
Phone (612) 642-0800
Apt. Bldg. Oth r: New Addn
Farm ��,Q� l�'�' Remod Re ir
Water Hfr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of the whife copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted wifhouf the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall � 0 to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amp:
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I her certi thaf I ins ed the elecfrical installafion dexribed herein on the dates sh
Irripation Boom o,.,...�.�., �_._
Fee
Invesifgatfve Fe�— " v �C--�--- -- �"
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS:
OFFICE USE ONLY This request void 18 months (rom validation date prinfed in this box.
IIIIIII �.�� �� ��/ � �
����������������I III (II���������������� ��
* 0 4 9 1 � 6 4 2* PLEASE PRINT OR TYPE
Requesf Dafe Ro h-in ins ion r uired?
ug pecT eq ❑ Yes � No Inspection Olher Thon RougMn: eady Now ❑ Will Call
�� �. 9 �l'ou must call the inspector when ready) Date Ready:
I, �,licensed contractor ❑ owner hereby request inspection of the above elechical work at: '
1ob Address �Sheet, Box, or Route No.� City Zi Code
1 �—1 1 �r10 �o.�-i� ��'Yl �30�
Secfion No. Township Name or No. Range No. fire No. Coun _
-t�O, 9( �1 b+ lQ
Power $upplier
EI hical Conh ctor (Company N me
's ����
Mailing Addr s �Con acfor or Owner Performing In Ilafio
�Au ed Sjpppture �Conhactor or Owner Performinp Insta
Phone No.
(� 3b� ''14b • 3�-7
License No.
1 �-- � �.�1-flC
��
�52�p -
iEE INSTRUCTIONS ON BACI
0
��Y�
—