P - 83330f RE(�UEST FOR ELECTRICAL INSPECTION —�.
5�' �-� 7 4 5 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 Industripi Farm Remod Re ir
Air Cond. Htg. Equip. Water Htr. load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above tl�e work covered by this request. Enter remarks in this space and on Ihe back of the white copy only.
i< i -�-c �� R'sU��c�..
Calculate Inspection Fee - This Inspecfion Request will not be accepted wifhout fhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 ro 100 Amps
Street Ltg./Traffic Si . Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA/L
Sign/Oudine Ltg. Xfmr. /�° �'� ! �
Alarm/Remote Confrol
�� � �ya.��v� � a.w� � KougM� �.t�,� '�� � UaI�,,,.1 � b �
$�QCIO� �OS `! /
F,� �3� � �
Investigative Fee —
THIS INSTALLATION MAY BE ORDERED DISC ECTED IF NOT COMPLETED WiTHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months From validafion date printed in this box.
_ � /� 5�
11811111111111II11111111 IIIIIIII��III��I �l 7S
* � 5 6 4 7 4 5 8* PLEASE PRINT OR TYPE
Request Date Rough-in inspection required� ❑ Yes No Inspecfion Other Thao RougMn: ❑ Ready Now Will Cail
lQr��( (You musf call the inspector when ready) Dafe Ready:
I, �►licensed controctor ❑ owner hereby request inspection of the above elechical work at:
1ob Addreu �Slreet, Box, or Route No.) Ciy Zip Code
lo$ l O l�o`. CU�-r V�- "� � c�
Secfion No. Townshio Name or No. Ranae No. Fire No. Coun
�upant Phone No.
..0 r 't ��Si K
rower soppGer /�ddreu �
NSP
Elecirical ConhacEor �Company Name� � ContracFor License No. Masfer Lic. No. (Plan
� �Gc-�r� nnec�iov� Ci�v��l� YY�.p�
n��i� �.�aa_a.�g � oW�, r „� i, �mu� �1 I�l� ., •�
\D i S�T w`
Authorized Si nahire (C a o Owner � rming Installafion) �- �� Pho�o_ �
. � �J
EB-00001 A-11 /96 . �p� gpqpD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY