P - 84534REf�UEST FOR ELECTRICAL INSPECTION —
/j /� ��� Q Q Minnesota State Board of Electricity
`T �r .,J V 1g21 University Ave., Rm. S-128, St. Paul, MN 55104
- Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Reoair
Air Cond. Htg. Equip. Water Hfr. Load 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.
{�—�-cJZN �t C °�
Calculate Inspection Fee - This Inspection Request will not 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
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR•s use oN�v TATAI
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irriaation Boom
I hereby certify that I inspected the electrical installation described herein on the dates stated
�
invesnganve ree� v - — �--/
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monlhs from wlidofion date printed in this box.
�1
��������������������������I��� lllll������������ ��� � �-i��
�
* � 4 4 1 2 9 8 ��K PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required? Yes No Inspection Olher Than RougMn: Ready Now ❑ Will Call
�+/�-� (You musf call fhe inspecfor when ready) Dafe Ready:
1, �licensed conhactor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreet, Box, or Roufe No.� Cify � Zip Code
°7 � � � �'rt�r - c,.�.� F r ���.
SecKon No. Township Name or No. Range No. Fire No. nty
����
Occupanf � Phone No.
,�i� c� ��7� `� Sc b-- I f�I 1
ontractor �Company Name�
1`a
)
dress Conkactor or Owner Performing
> -�1-'l �. �..57—
Signoture�onhacfo�or�wner Perfori
�
U
r
O�
License No.
� 1 �L
Master Lic. No. �Plant
>
�
�% c .�