P - 80934REQUEST FOR ELECTRICAL INSPECTION �'"=�
�-�,,,,+� � n p � Minnesota Sta� Board of Electriciry " ��
( L. O 1821 Universi Ave., Rm. 5-128, S1. Pau1, MN 5510A
Phone (612) 642-0800 -��'
_ � ._. „u_ r�.�,,... � New Addn
A'r Cond Hfg Equip. Water Htr.� I Load M mt Ofhec
� � � R � { Elec H t� Temp Serv ce �
"X" above �he work rovered by �hrs request Enler remorks m this spoce and on fhe back of fhe whde c py ly
— �Har�c,�o bon ��s� sr;ti�,�.c -ru
Zoo fl c�R��r �R�lR 5��� , SN�IaF.,�
r� F�r� s o x w/��{ P�SS
Calculote Inspection Fee - ihis Inspecfion Reques� will nol be accepred wiihout lhe correcl Fee:
O[her Fee B Service Entrance ' e Fee # CircuitsiFeeders Pee
Mo6ile Home Park Stall t 00 � mps Q� 0 �0 100 Amps
Streei Ltg./TraHic Sig. Above 200�Amps Above 100 ^Amps
*. _
INSPECTOH'S USE ONLY
!hotl
Boom
herein on
'�� _'rN�S INSTALLATION M BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. _�_
OFi10E USE ONLY This requert wid 18 months frcm validMion dme prin�ed �m �hls 6ox.
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PLEASE PRINT OR TYPE
Reaves� Da2 fto�gh+n inspe��lon required? ❑ Ye..
8���1 �Q Q In�penia� O�her TM� RougMn: dy N w I Call
� // �You musr call ihe inipxror when reody) Dme Rmdy: �'L �.�
I, � licensed contmcbr � owner hereby request inspection af fhe obove elecfric¢I work at:
lab Address (Sneer, Box, or ftame No. P
4�5 ��"� F� �� WA� ��ry% ��fl��Y Z, �od4�Z„ I
Seclion No. Township Nome or Na. Rn�oe N,. c�.o n�,. �___.. .
O po �
«TyM � M►T�1 �,�,ro�h��r►
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I Comrocror (Compony Name)
G-'hoVt=�S C�� ���a,�t-
Addresa�CantradoroeOwrer Performing Insbllmionj
�R19 oR�c�n/ /kUC� Nn
�d s�s�aw,e �eo�na�ro, o, o�A, PP.r�,m�,,,, i„�,.,n,,,,,..� .
E600001A-11 B(q6 STATE60ANDCOPV-SEE
Phone No.
6ti2-5f1-6`}05
tmnor License No. MasRr Lic Nn. {Plam Elect. Only�
G�} 03° 65
,aa 11.�N P RY� MP( �5 ��r�
Plwne No.
61z-3i5-3`�55
)NS Ory BqCK OF YELLOW COPY