P - 80686REGtUEST FOR ELECTRICAL INSPECTlON �
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7 p C F1; � A/I � Minnesota State Board of Electriciry
O e �f �-t 1821 University Ave., R�n. S-128, St. Paul, MN 55104
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r Phone (612) 642-0800 "�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remorks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without fhe 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 ONLY TOTA �a
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Contro!
Swimming Pool
I hereb ceAi that I ins ted the electrical installation described herein on the dates stated
I�figatiOn BOO RougMn �°fe
Special Inspe n Date
Firwl
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN i8 M_ NTHS.
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� OFFICE USE ONLY This request wid 18 monfhs from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Dote Rou h-in ins ion r
g pect' equired? ❑ Yes '[�No Inspecfion Other Thon RougMn: � Ready Now � Will Call
���� � 9 9 (You musf call the inspector when ready) Date Ready:
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I, �(icensed conhactor ❑ owner hereby request inspection oF the pbove e�ectrical work at:
Job Address (Sheer, Box, or Roufe No.) C� P
3/%—/�• E. QS' R'%rn e I�er y J�i^1 �/i° z� c«�
Secfion No. Township Name or No. Range No. Fire No. County
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Occupanf Phone No.
P! �� � F�"�'� '7 86 - 7 77 Z
Power Supplier Address
Elechical Cootmcror (Company Name) Conkacror License No. MasteP Lic. No. �Planf Elecf. Only)
/�Ts Ec�c�'�c?r e�4 0 �y89
Mailing Address (Conhacfor or Owner PerForming Installation�
a'71� —�S7 f� u e t�t�J Z�•-•� r•, . � n- S53 9�
Aulhorized SignaNre �Conkactor or Owner PerForming Insfallation) r .� �":� Phone No. G�.�
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E&00001 A-1 1 8/96 t STATE B RD C Y- SEE INSTRUCTIONS ON BACK OF YELLOW COPY