P - 80361C��879-077 �
REQUEST FOR ELECTRICAL fNSPECTION � -.
Minnesota State Board of Electricity
182� Universiry Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us '� '
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Calculate Inspection Fee - This inspection Request wili not be accep►ed withou► the correct fee:
Other Installations Fee # Service Entrance Size Fee # Circuih / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street ltg. / Traffic Sig. Above 200 Amps Above 10� Am s
Transformer/Generator INSPECTOR'S USE ONLY TOTAL�/
Sian / Outline Lta. Xfmr. 7�� SI
iote Control
Pool
I hereb certi that I ins ted the eleckiwl installation described herain on the dates stated:
o _,:_t ,. Roug(��-In _. . ..� ��e ���_ Dafe �J.y' / �a
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� Imestigative Fee � � ���' — - j �'2, �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1$.MCINTH�_
�—� � � OFFlCE USE ONLY This request void 18 moMht kom validation date printed in this box.
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� 0 8? 9 0? 7 6 * �J�73
PLEASE PRINT OR TYPE
Request Dafe a Rough-in inspecfion required2 Yes ❑ No Inspecfion Other Than Rough-In: ❑ Ready Now Will Call
3 �� �(,/ You musf call the inspecfor wh ready Date Ready:
1, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Streat, Box, or Route No.) C�h! � Z�P CO�
ss�� �r�ss .�a�cc�� F�.�a�l� S'
Secfion No. Township Name or Range No. Fire No. Cou
,�r� a5` �iU�� a.
Occupant I 'D�� � /' � f LZ
/{ i ��
/ V vi v
Pawer Supplier Ad<
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Electrical Conhactor / Company Name �
Standard Electric Co. Inc.
Mailing Address (Contractor, Company o Owner Performing Ins
2672 Maplewqpd�r. , Maple�O
A���horized Sianature IContm oanv or Owner Pe min
2 �19 STATE BO COPY
� Conhacfor License �
�' =� CA01715
d ._ MN 55109
Phone No.
Master Lic.
Phone Number I
(65� 484-8044
SEE INSTRUCTIONS ON BACK OF YELLOW COPY