P - 81116REQUEST FOR ELECTRICAL INSPECTfON
C�� C� U�-16 5� Minnesota State Board of Electricity � �'
1821 University Avenue Suite 5-128, Saint Paul, Mlnnesota 55104-2993
• (651) 642-0800 www.electricity.state.mn.us " '
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
f�dd C���'a�aY h�-o-� �`'�
��t ��7-?���
�'1� CI ��
Calculate Inspection Fee - This Inspection Request will not be accepted without t e correct fee:
Mobile Home Park Stall
Street Ltg. / TrafFic Sig.
Tra nsformer/Generator
Sign / Outfine Ltg. XFmr.
Alarm/Remote Control
Swimmina Pool
# Service Entrance Size fee # Circuits / Feeders Fee
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL _ _ ✓
a��,�j�
I herebvi certifv that I insoected fhe elechical installation described herein on the dates stated:
ungarion noom Rough-In Dare
Special Inspect
Final Date �-y�
Investigative Fee �/
THIS {NSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1S MONTHS.
OFFICE USE ONLY This request void 1 S moMhs from validatio� date printed in this box.
. � o2C� �S�J
IHNN�IIIIIINI�N�����I��I�
* 0 8 6 6 1 6 5 4* ���`�
PLEASE PRINT OR TYPE
Requesf Dafe _� Rough-in inspection required$ ❑ Yes o Inspecfion Other Than Rough-In: ❑ Ready Now ill Call
lYou musi call the inspector when ready Date Ready:
1 ✓
1, licensed contractor ❑ company ❑ owner hereby request inspection oF the above electrical work at:
Job Address (Sheef, Box, or Route No.) City Zip Code
�.-��01 �.exv,� T�errac.�; �� �r-j�t�,►., ss�32
Secfion No. I Township Name or No.' � � I I
Occupant � o
tYn ( o �� .�,: � i
Power Supplier
Ele�t�ical Con��j��o��.l��e ��L+T., SNC.
��,562 CENTRAl.A1fE. N.�.
Mailing Address ( onha��� q�r��erForming
Authorized S ture (Con actor, oi pony or Own� Perfon
E&OOOOtA-1 5l1999 STAT@ BOARD.COPY
��-# - t�-��
. Masfer Lic. No. (Planf Elecf. Only)
SEE INSTRUCTIONS ON BACK OF YELLOW COPY