P - 79914.
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Home Duplex
Commercial Industrial
Air Cond. Htg. Equi
Dryer Range
,� "X" above the work covered 6
REQUEST FOF� ELECTRICAL INSPECTION m�;�
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 `�'
Apt. Bldg. Other: /L� /�✓"T/ ` New Addn
Farm `' �� Remod Re air
Water Htr. Load Mgmt. C�er:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of the whi copy only,
Calculate Inspection Fee - This Inspection Request will nof be accepted wiihout fhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Ai
Transformer/Generator INSPECTOR•s usE oN�v TOT,
Sian/Oudine Lta. Xfmr. '�
fee
�❑
Swimming Poo
•
I hereb certi that ins ted the elechical installation dexribed herein on the dates slated
Irrigation Boo RougMn -
Special Inspection "' '�
Firwl D
investigative Fee "'�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONT .
OFFICE USE ONLY This request void 18 monThs from validaTion date printed in li�is box.
I IIII II III II III II �II II III II III II III II III II I� I�I
* 0 8 0 2 3 3 0 1 * �����'6 �!/Sd
PLEASE PRINT OR TYPE
Request � R h-in ins on r ui�ed? Yes
� �/�� oug pecfi eq ❑ No Inspection Olher Than RougMn: ❑ Ready Now Will Cdl
�You must call ihe inspecfor when ready) Dafe Ready:
I, ❑ licensed contractor �owner hereby request inspection of the above electrical work at:
Job Addreu �Sheet, Box, or Roufe No.� Ciy Zip Code
� � �i �-�'d MN �Sy �..
Section No. Township Nam or No. A^ Range No. Fire No. Co n1y
�''�60 ay no kc�
Occupant� j � � /� � Phone No.
d- 1�.1ClCl"i Lk� � S� b �
Power S�lier _ dress �
c�e.�/ r'n 1 s /1/�0►^�. 7J � v.
Elechirnl Contraclor �Company Name) C hacbr License No. Masfer Lic. No. (Planf Elecf. Only)
W/W�
Mailing Address (Confracfor or Owner Performing Installafion)
' �Q�
Authorized Signature �Conhacror a Owner PerForming Installation� P one N.
� � 1[l�.%—L� 1�.7
E 1 1 8/96 p7� BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY