P - 81036RE(IUEST FOR ELECTRICAL INSPECTiON
�� � � � /� � � Minnesota State Board of Electricity
., �� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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r 2 p` Phone (612) 642-0800
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Home Duplex Apt. Bldg. Other:
Commercial Industrial Farm
Air Cond. Htg. Equip. Woter Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above fhe ork covered by this reqlesi. Enter remarks in fhis space and on
i�'�%��`�° AC G�� f
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Calcula% Inspecfion fee - This lnspection Request wi!! not be accE
Other Fee # Service Entrance Size
Mobile Home Park Stall 0 to 200 Amps
Street Ltg./Traffic Sig. Above 200 Am
Transformer/Generator INSPEC70R'S USE ONLY
Sign/Outline Ltg. Xfmr. h,(y—
Alarm/Remote Control 7-1Y-c/
Swimming Pool
I herebvi ceniH Ihat I inscected the
without the correct fee:
Fee # Circuits
0 to 100 A
Above lOQ
�
New
coaY
Fee
��
hinal ! UO�r/� 03
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This roquest void 18 months from wlidafion date printed in this box.
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PLEASE PRINT OR TYPE
Requesf te Rough-in inspecfion required? ❑ Yes �o Inspecfion Other Than Rough-In: �eady Now � Will Call
(You musf call the inspector when ready� Date Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address �Sfreef, Box, or Route No.) Ciy Zip Code
6'dj% letc �'ro�' TB�"/�tc� r'a� S� y3 �
Section No. Township Name or No. Range No. Fire No. ouny _ �
,�✓
n
wctor (Compan�e�
r �
:ss (Conhacfor or Owner
7 � �°�.i ,�_ Li .- SS�i
Owne rforming Installafion) Phone No.
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STATE BOARD COPY - SEE INSTAUCTIONS ON BACK OF YELLOW COPY
Conhacfor ticense No.
No.
t-SS6-DS6
MasFer Lic. No.
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