P - 81278REQUEST FOR ELECTRICAL INSPECTION �""`�
��i fy ,� n A�i Minnesota State Board of Eleciricity
( U °} G 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �j� �
� Phone (672) 642-0800 •.
Home Duolex Ao�. Blda. Other: New Addn
f Commerciol Industrial Farm Remod R<
ir C Hfg. Equip. Water Hir. Load Mgml. Other.
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this reqaest. En�er remarks in this space and on Ihe bock of the whi�e ropy only.
�/�
Calculafe lnspec�ion Fee - ihis Inspeclion Request will nof be accepled withouf the mrrect fee:
Other Fee N Service EnUance Size Fee # Circuits/Feeders Fee
Mobile Home Pork Stall 0 b 200 Amps 0 l0 100 Amps
$freef L�g./TmHic $ig. Above 200_Amps Above 100_Amps
Transformer/Genera}nr MSPECTORB USE ONIY TOTAL
Dore
Imestigofive Fee ��� ` — D �3 —C�d
THIS INSTALLATION MAV BE ORDERED DISCO ED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request wid I B months from volidation dote prinled in rhis box.
��I�����I���������������I�����h����� �� • 'S"�
*a��o44��* a�q6
PLEASE PRINT OR TYPE
RequeFst Dare Ro�gh-In inspeciion requlredz ❑ yas ❑ No Inspection Other TVwn Roogh-In: Ready Now � WIII Call
y/J •� • g� (Yoo must mll ihe inspecbr when readyl Date Neady:
I, li ensed conhactor ❑ywner hereby request inspectian of the above electrical work at:
Jo Address �sreet, Ba�, or Cly Zp Code
� �o � � Q4D �— S .� �
Sec�ion No. Township Nome or No. Ronge No. Fire No_ CoonN /1
I Ocwpanl
Coon Rapids. MN 55
Pha�ne+N�^o'�.
V /� r
Conhomu License No. Nwster G<. No.
ING. /�.���i�/_ .M�.�