P - 80323�)���91?-�65 �
Home Duple�
Commercial Indusfr
Air Conditioner ' jitg. 6
Dryer Range
"X" above the work co
Calculate Insp
Other Installations
Mobile Home Park Stal
Street Ltg. / Traffic Sig.
Tra nsformer/Generator
Sign / Outline Ltg. Xfm
Alarm/Remote Control
Swimminq Pool
Farm
REQUEST FOR ELECTR�CAL INSPECTION �
Minnesota State Board of Electricity �'
1821 University Avenue Suite S-128, Sain[ Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us "��
Repair
II Elec. Heat I I Temp. Service I
�ed by this request. Enter remarks in this space and on ihe back of ihe white copy only.
� �° ��--G`-4O'!�'t ���- 7?% �%0-�c�
tion Fee - This Inspection Request will not be accepted without the correct fee:
Fee # Service Enhance Size fee # Circuifs / feeders Fee
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL�M �y'C�
O�
Date
I I Invesfigative Fee � �� � �,,,,_ _-_._�� I V�( -� Q f I
a -
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months From validation date printed in this box.
I����������������II�IIIN�� � ao.�
* 0 9 1 7 5 6 5 4 * %7/J�
PLEASE PRINT OR TYPE
Request Da1e Rough-in inspection required$ ❑ Yes �lo Inspeclion Ofher Than Rough-In: ❑ Ready Now �ill Call �
3 -a '
3— Q� You must call the inspector when reody Date Ready:
I,�icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
lob Address (Skeet, Box, or Roufe No.) � Ciy Zip Code
� Ymv _ �--.�.��; �--�,�. _ ,.,�i �'�.�2.
Section No. Township Name or No. Range No. Fire No. County
Occupanf
� %�--s �-`-`-�
Power Supplier (� �
�
�a � �' �-c � .
• �Ci.
Phone No.
s-�a -���
License No.
Masfer Lic. No.
� � �4�'�'�U`�-c� � I��l �� s�-��o�l
EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF VELLOW COPY