P - 83579RE(]UEST FOR ELECTRICAL INSPECTION �-
��`F - 6 3 3� Minnesota State Board of Electricity
1 � 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 '��
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Htg. 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 the white copy only.
Calculafe Inspection Fee - This Inspection Request will nof be accepfed without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Sfall 0 to 200 Amps 0 to 100 Amps
$treet Ltg./Traffic Sig. Above 200 Am s Above 100 Ai
Transformer/Generator INSPECTOR'S USE ONLY TOT,
mote Control
� Pool
i
Boom
Fee
��so
Investigative Fee I F��� ( � I� (�'j`� �,
— �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
III�II11111IIIliIIIII111111�Ml�llllllil��l� � ���5,/��
* 0 7 2 4 6 3 3 3* (J�`t �
PLEASE PRINT OR TYPE
Request Dafe R h-in ins on r uired?
oug pecli eq ❑ Yes o Inspection O�her Than RougMn: Ready Now � Will Call
�' .��-�� (You must call the inspector when ready) Date Ready: �3 3� �9�
I, licensed contractor ❑ owner hereby request inspection of the obove electrical work at:
Job Address (Sheet, Box, or Route No.) Ciy Zip Code
�/D --�2ice �►-ee�Te�-,-a � e ��.c�/e
Section No. Township Name or No. Range No. Fire No. County
Occupanf
J0� �Z ��
Power Supplier qddreu
Elechical Contractor �Company Name)
%ZTS El�cT�2iC
Mailing Address (Conhactor or Owner PerForming Insfallalion)
�ika �
Phone No.
S7/ �.638'
Contraclw license No.
Cf+o r Y�'9
S�-!� -�.�5'7� �� N w 2i �+; r... . �'YI n.��3 9�P'
Authorized Signature (Confracror or Owner Performing Inslallation) p. ' Phone No.
�s�� � � �', � �
�� ��
&00001 A-11 8/96 STATE AR PY - SEE INSiRUCT10NS ON BACK OF YELLOW COPY