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Home Duplex
REGIUEST FOR ELECTRICAL INSPEC i��.
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 ��
Phone (612) 642-Q800 `���
Other: New Addn
Commercial Industrial Farm emoc
Air Cond. Htg. Equip. Wafer 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
1�t1 � i4� B l-�s'fc., � iv�
Calculate Inspection Fee - This Inspection Request will not be accepied without the correcl fee:
Other Fee # Service Entrance ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 00 Amps 0 to 100 Amps
Street Ltg./Traffic S+g. Above 200 Am s Above 100 Amps
Transformer/Generato� INSPECTOR'S USE ONLY TOL� �
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Sign/Outline Ltg. Xfmr. ��,A..,ccc p •
J�`
Alarm/Remote Control �� r�� �.-v ^ Gy� �� _ g7� •,�T�'3
Swimming Pool
I hereb certi that I ins the elechical inslalla6on described herein on the dates stated
irri9atiOn Boom Rough-In �a 2 O.r �
Special Inspe ' a
� Finol _ Date .:,, ��-L,�'rf
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE U.RE ONLY This request void 18 monlhs 6om validation date printed in fhis box.
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* 0 6 8 9 3 9 9 77Q�
PLEASE PRINT OR TYPE
Request Da ' Ro h-in ins �on r uired? es
ug pecf eq ❑ No Inspection Other Than Rough-In: ❑ Ready Now ill Call
� (p � (You must call the inspector whe ready� Date Reody:
I, icensed confractor ❑ owner hereby request inspection of the above electrical work at:
Jo Address (Sheet, Box, or Route No.) Ciy Zip ode
B 3 0 �Noor2a9 �2� �{. �i24D�- �s"`�l3 �,
Secfion No. Township Name or No. Range No. Fire No. Coun
�9 No�.,�
Occupanf Phone No.
�v��, �cw w�c.� co� �—s �—os-a3
Power $vpplier Address
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Elechica� Confracfor (Company NameJ Conhacfor License No. Masfer Lic. No. �Plant Elecf. Only�
f�R�c���� �c,�c.-cncc � NC,� C/-�c�o �S' ��''1 D l co � 3
Mailing Address (Conhocfor or Owner Performing stallafion�
3 b0� k/r� �rN �'�S"la%�
Authoriz ign re (C ntra r o er orming Installati Phone No.
6s�i-ys"a �3 3
EB OOOQ1 A 11 8/96 STAT BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY