P - 81279i-
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Home Duplex
Farm
REQUEST FOR ELECTRICAL INSPECTION ��' -
Minnesota State Board of Electricity 3
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800 ;�_- �
Remod
Air Cond. Htg. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by �his request En�er remorks in fhis space and on the bock of the white
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Calculofe lnspecfion Fee - This Inspec/ion Request will not be accepfed withouf the mrred fee:
O[her Pee # Service EnUance Size Fee # Circuits/Feeder,
Mo6ile Home Park Stall 0 l0 200 Amps 0 l0 100 Amps
Sireet Ltq./TroHic Sig. Above 200 Amps Above 100 A
copy only.
Fee
¢�/Genembr INSPECTOH'S USE ONLY TOTAL >�
line L�g. Xfmr. �yN- o v
mote Control G _� -
j Pool I hereb cerii iv-� I �ns ecied rhe elxrc�ml �nstallar�o� de�cr�bed herein on ihe dmex smied
Baom ko�oh�io ome
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE U5E ONLY This requesi void 1 B monlfis Irom valldafion daVe prinfed in Iliie box.
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*o��a44�n: 0?696
PLEASE PRINT OR TYPE
a��e�, oare �� ea9n.�� ���P�ro� ,����,ed: ❑ ve� ❑ No i�,�.,�a� o�ne, rha� ao�yn-i�: eod� Now O w�n cau
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I, ' ensed contmclor ❑ owner hereby request inspeclion of ihe above electriml work al:
lob Addmss (Sheet, Bax, r oute No ) //' Ci� `/) Zip Code `/` �
i— � . . _ . / 7
secnon No. rownship Name o.
Occupom � ��
C�en Rapids, MN 5y5s#33
�mo��d s�9�am.e ie«�� y,�.ao �e� Peha
Phore No.
License
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SEE INSIAUCTIONS ON BACK OP YELLOW COPY
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