P - 80097REGIUEST FOR ELECTRICAL INSPECTION �_
�� L= 3 61 � Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other �.�-t New Addn
Com i I Industrial Farm d� .� Remod Re air
Air Htg. Equip. Water Htr. oad Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculafe Inspeciion Fee - This Inspection Request will not be accepied without fhe correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Oudine Ltg. Xfmr. � �•� d
Alarm/Remote Control
Swimming P
I hereb certi �at I in the electrical installafion described herein on ihe dates stated
Irrigation B RougMn Dare
Special Inspection
Investigative Fee F �re�/- ,s �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void�monlhs 6om wlidation date printed in this box.
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* 0 8 0 2 3 6 1 6* �5� a�, $D
PLEASE PRINT OR TYPE
Request Date Rou h-in ins tion r uired? ❑ Will Call
_/' �� g pec eq ❑ Yes o Inspection Other Than Rougffln: Ready Now
�You must call the inspector when ready� Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreer, Box, or Roufe No. Ciy /� Zip�
/? N �� 302
ecfion No. Township Name w o. Range No. Fire No. ounly
� � k�
..10n/,/t .� I�i/C.5 jr - � e3 .J %l'df�o�
Power Supplier Address
�C� �- C.S o �r/-
hical onhaM (Company Name) Contractor License No. Master Lic. No. (Plant Elact. Only)
. �'///w� �/\ �//�/�� /�Q , .
Mailing Address �Conkactor or Owne,F Perforinirw InstallaKonl I A . A __ . .�
er�' Installation) � I � �
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY