P - 82948REQUEST FOR ELECTRICAL INSPECTION
�� � � � -7 � � � 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 Re air
Air Co Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" abo e work covered by this request. Enter remarks in this space and on the back of the white copy only.
e�i bh �.�, �cK� �+�-�- a,o. c� w► r� � d d►-�� �,..t � a hoks.e�
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entranc ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall t 0 mps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR•s use oN�r TOTAL C
Sign/Oudine Ltg. Xfmr. � • 7 �
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the eleclrical installation described herein on the dates sMted
Irrigation BOOrti� � Rough-In � � D
Special Insp � _ 'Z
� Final Da� 7 �
Investigative Fee �-v
THIS INSTALLATION MAY BE ORDERED DISCONNEGTED IF NOT COMPLETED WITHIN 18 MONTHS.
. OFFICE USE ONLY This requesf void 18 monihs from validation dafe printed in this box.
� I� �� III II I�� II �II��� I�� �i II{ �� {I� II �� �(� •. 7� �
* 0 6 3? 7 6 3 4* ��`'�O�
PLEASE PRINT OR TYPE
Request Dafe Rou h-in ins on r uired$ es
g pecfi eq ❑ No Inspection Other Than Rough-In: ❑ Ready Now ❑ Will Call .
��� �� 4 (You must call the inspector when ready) Date Ready:
1,�licensed controctor ❑ owner hereby request inspection of the above electrica) work at:
Job Addrass (Sheet, Box, or Roufe No.) Ciy Zip Code
oa o� o,,.� O�e�� N r- F�,� dl� 55ti3 a
Section No. Township Name or No. � Range No. Fire No. County /
�%d�iil�
Occupont Phone No.
S-�ee�- i�e� e.,�.� 5��- qy2(o
Power Supplier Address
N S � 3!!5 ('e.wi'.t otcv� �%
Elechic I Co hactor �Company Name) � Conhacfor License No. Master Lic. No. �Plant Elecf. Only) .
i�e�e.l. �/c�-��� ��' � �, ao d 5 D b
Mailing Address �Conhactor or Owner Perfo�ming Insfallafion) J
q 2 0 0 �'Sa n�� S-�i � YV � lI4 ai1C-� %1%h% ,�S �i Y%
Aufhorized Sig fure �Conhactor or Owner PefForming In IaKon) Phone No.
7B'3 - 2S1 d'
EB-0OOOI A-1 1 8/96 STATE BOAHD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY