P - 80253�J'�-179 �
Home Duplex
Commercial Industri
Air Cond. Htg. E<
Dryer Range
"X" above the work covered
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800 y� '�'
Apt. Bldg. Other: j � New Addn
Farm l`��� �. Remod Re air
Water Htr. Load Mgmt. Other. � v,,,�' �2.,`T S
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of the whi►e copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted wifhout the correct fee:
Other Fee # Service Entrance Size Pee # Circuits/Feeders
Mobile Home Park Stall 0 ro 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Ar
Transformer/Generator INSPECTOR°S USE ONLY TOT
$ign/Outline Ltg. Xfmr. r
Alarm/Remote Confrol
Fee
....�_.._.. ___'�r• - � ♦ nouyrrin � � _ �_ �
Speciallnspec R
Final - Da I_ �•_',
Investigative Fee — v��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONIY This requesf void 18 months from validation date printed in fhis box.
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* 0 8 0 2 1 7 9 2* � �
PLEASE PRINT OR TYPE
Requesf Date Rough-in inspecfion required? �Yes ❑ No Inspecfion Olher Than RougMn: ❑ Ready Now ❑ Will Call .
, I '�, 1�} do-b (You must call the inspeclor when ready� Dote Ready:
1, ❑ licensed conhactor �owner hereby request inspection of the above electrical work at:
Job Address (Sheef, Box, or Route No.) City Zip Code
��► �. s T�� r. «�,., 1� �.., � r- �, d�� y � s u Z �
Section No. Township Name or No. Range No. Fire No. Couny
�t,.flk �
Occupan�_ . . Phone No.
� �c� �,�a� S� a - �3� �
Power Supplier ^ ' �j Address
'v � i
Elechical Conhacror �Company Name� Conkacror License No. Masrer Lic. No. (Plant Elecl. Only)
Mailing Address (Conhactor or Owner Performing InsMllation)
� �
Authorized Si e Conhacror or Owner PerForming Insfallafion) � Phone No.
E&00001 A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY