P - 83174REQUEST FOR ELECTRICAL INSPECTION -_
4 q� 12 4 Minnesota State Board of Electricity
�• � 1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: f�ew Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Hh. load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enter remarks in this space and on the back of the white copy only.
11�1.M5�.• un1(�V11 �
Calculate Inspection Fee - This Inspection Requesi will not be accepted without the correct fee:
Other Fee # Service Entrance Siz� Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 ro 200 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
TransformerjGenerator INS� ���stu$E ONL� �t l`d " TOTAJrL s�
Sign/Oudine Ltg. Xfmr. � �
Alarm/Remote Conhol
that 1 insoecled the elechical insfallafion described herein on ihe dates sta�ed
Boom
Imestigative Fe I j} r���� �,x–�r— ��"�' �-��
THIS INSTALLATION MAY ORDERED dSCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE U� ONLY This request wid 18 months 6om validafion date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe. Rough-in inspection required6 ❑ Yes o Inspection Other Than Rough-In: Ready Now ��11 Call
}� l��� (You musf call the inspecfor when ready� Dafe Ready:
I, � licensed confractor ❑ owner hereby request inspection of the above electrical work at:
lob Address (Sheef, Box, w oule No.) Cily Zip Code
Ko p ` c�a-�'�'� �,r; '�1.3�
Setfion No. Township Name or No. ange No. Fire No. Co n
Occupant
'Flu�+1�-
Phone No.
5''ll-�tO9
�ntractor (Company Name) Contractor License No. A
nns h� fl.�c�-r�� C�-ooi139
Iress �Conhactor or er Performing Installation) /�
' 1 �3 � �-A0. . �
ii re(C or Owner Perfurming Instal � n� j��^ �. p
iJ �� /
� 8� 6 STATE BOARD COPY - SEE INSTRUC710NS ON BACK OF YELLOW COPY