P - 83534y
:724-902 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �:
Phone(612)642-0800
Home Duplex Apt.8ldg. Other: New c
Commercial dustrial Farm Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on ihe back of the white copy only.
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Calculate Inspeciion Fee - This Inspection Reques� be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�v TOTAL/�
Sign/Oudine ltg. Xfmr.
Alarm/Remote Control
that I
Boom
the dates sfaled
Invesfigative Fe�G (} / �„ ` Ej -��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from volidafion date printed in this box.
IINIIIIIINIIIIINIIIIIIIIII��M�lllllll�l�l� � ����
* 0 7 2 4 9 0 2 2* �379
PLEASE PRINT OR TYPE
� Requesf Dafe Rou h-in ins fion r uired?
g pec eq ❑ Yes No Inspection Ofher Than Rough-In: ady Now ❑ Will Call
' 2'� �You must call the inspector when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job A dress ISheet, Box, or Roufe No.l CiN . Zio Code
xttion rvo. iownsnip rvame w
Occupanf •
Power Supplier
Elechical Conhacfor �Company N�
No. 1 Fire No.
Phone
Conhacror License No. I Master Lic. No.
"'°"'"s "�reu ic°""°2°5���t���'"�ue North, 301, Golden Valley, MN 55427
Authorized Signature (Conha Insfallatiqn) �� I Phone No.
544-3300
EB-00001 A-1 1 B/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY