P - 808551�'� � REQIf�ST FOR ELECTRICAL INSPECTION §�'�
7 O� u 7 6 4 Minnescta State Board of Electricity _•�
1821 Universiry Ave., Rm. 5-128, St. Paul, MN 55104
� Phone (672) 642-0800 ..,_
Home Duplex Apl. Bldg. Other: New Addn
Commerciol Indusirial Form Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Ronge Elec. Heaf Temp. Senice
"X" obove rhe work covered by �his request Enter remarks in �his space ond on Ihe back of fhe white copy only.
(ii�P�'J �n5�,��w� o� r�ew 4'gl.�s.
Colculafe Inspecfion Fee - 7his lnsp
Other Fee
Mobile Home Park Stall
Sfreef Llg./Traffic Sig.
Transformer/Ge nerator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irriqotion Boom
will not be amepfed wifhoul Yhe correcf fee:
e Enhance Size Fee # Circuits
0 to 2Q0 Amps 0 to 100 A
Above 200—.
INSPECTON'S USE ONLY
/1> Fr�
ihot
��/1%/%%GL/i�
�alla�ion descnbed herein on
Fee
Investigafive e � � �� IV��j —���60 I
I THIS INS7ALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFIGE VSE ONLV This �equest void 18 monlhs fram valldaFon dare printed in ihis box.
���������I��������������������1�����������h a �a/�`s/�
* 0 7 8 7 7 6 4 C] * 'Y 57b
PLEASE PRINT OR TYPE
Reqaesf Dare Rough in inspecnm reqoired? ❑ Yes No InspeCion Other Than Rough In�. ❑ Ready Noy�ill Call
(You musl call the'mspector when ready� Dare Reody:
I, icensed controctor � owner hereby request inspection of the obove eleclricol work at:
Job Address �Sbeet„�o,, a Rook No.� Clry Zip Cade
. I mwnsnip rvame or rvo. I noi
�rv-el �Y1�Nac.�
olier Ad
o��mcror �Company Name�
!r✓l �.�1 �Yi C
dress (Contr �or w Owner Perbrming Imbl Fon�
�5,����� ��
S�gnaNre (Conrcacbr or Owner Pedorming Insmlla�i<
�2
�