P - 80249��� ���� REQUEST FOR ELECTRICAL INSPECTION �����,-,.
O 0�,��17 7� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
, Phone(612)642-0800
Home Duplex Apt. Bldg. Oth r /O �/ ' New Addn
Commercial Industrial Form 7 i/' Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Hept Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate lnspection Fee - This lnspection Request will noi be accepted withoui 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 TOTAL, _
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Conhol
1 hereby certifv 1ha� I insoec�ed the elechicq�,icstalhtion described herein on Ihe dales
Boom
Investigative Fee r��� � � �� �
THIS INSTALLATION MAY BE ORDERED DISCON D IF NOT COMPLETED WITH N 18 MONTHS.
� OFFICE USE ONLY This request void 18 months from validation date printed in this box.
I�ill�llllllllll�il�������!lIN�I�I�I��I��l���� • ��-�
* 0 8 0 2 1 7 7�, * 5/�
PLEASE PRINT OR TYPE
Reque� �' �� Rou h-in ins on r uired$ es
g pecli eq ❑ No Inspecfion O�er Than Rough-In: ❑ Reody Now Will Call
(You musf call the inspec�or when ready) Date Ready:
I, ❑ licensed confractor � owner hereby request inspection of the above elechical work at:
Job Address �Sheet, Box, or Route No.) City Zip C
�D /��cC CRCC� T-t'DQ � ��,��e+ f�f/��
.Secfion No. Township Nqme or No. Range No. Fire No. County � .
�3� �� A,�.bl�
Occupanf Phone No.
�.16 t Cv� �r+�j��Se.
Power Supplier �� qddress �� � ��� t
^/ � � � �.
V
Elechicol Conhacror (Compbi�ame� _ Conhactor License No. Masfer Lic. No. �Planf Elecl. Only)
.Mailing Addreu (Contracrorpf�ner Performing
Authorized Signafure (C frac or Owner Performing I�sfallafion) • l� � Phone No.
/���%�--""' �/.1 �'7/ �i��
A-11 8/96 STATE BOARD COPY - SEE INSTRUC710NS ON BACK OF YELLOW COPY