P - 80352REOUEST FOR ELECTRICAL INSPECTION °'E
�`t .� � 8 6 3 Minnesota State Board of Electricity
i821 University Ave., Rm. S-128, St. Paul, MN 55104 �
F Phone (612) 642-0800
Home Duplex Apt. Bidg. Other: New Addn
Commercial I�dustrial Farm Remod Re oir
Air Cond. Hig. Equip. Water 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 ihe white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the 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 TOT
Sign/O�d+ne ltg. Xfmr. .
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins the electrical installafion desc�ibed herein on the dates stated
IfflgOtlOfl B Rough-In . Daf� �d
Speciallnspe n �
Final D
Investigative Fee -2- .-0-�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MOhTHS.
OFFICE USE ONLY This request void 18 monlhs Fom validation dafe printed in this box.
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* 0 8 4 3 8 6 3 2*
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PLEASE PRINT OR TYPE
��est D RougMin inspeciion required? �►Yas ❑ No Inspection Other Than RougMn: ❑ Ready Now 0 Will Call
� (You must call the inspeclor when ready) Date Reody:
i, ❑ licensed contractor ❑ owner hereby requesf inspection of the above electrical work at:
Job Address (Street, Box, or Roufe No.) w �� City � � Zi� e��/
/ � �� �
Secfion No. Township Name or Range No. Fire No. Counly
D ��
Occupant / ,�n / Phone N�Q� — w �� �
VV (� i �
Power Supplier Address
�'1 � � � VlSli��
" al C hactor (C Name) Co ac r License No. Master Lic. No. (Plant Elecf. Only�
-� c s�� � n � �2 .SS
iling Address (Confr or er Performing Instoll�qfion) � � � �/� � q
7 CiI ��f''1 V'C � � V'!.� /"V �'J� � ! �
Autho � Si ture a e o ing Instalfp�or� �� P�e No.
2� � ��� �����
E ,411 8/ STATE ARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY