P - 84425.
�26-981
Home Duplex
Commercial Indusfri�
Air Cond. Htg. Eq
Dryer Range
"X" above the work coverP.�
---
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of E�ectricity �
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Apt. Bldg. Other: New Addn
Farm Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service 1`y.fd 'c��0.C2
request. Enter remarks in this space and on the back of the whiie copy on/y.
Calculaie Inspection Fee - This Inspection Request will not be accepted without fhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps
Street Ltg./Traffic Si � 0 to 100 Amps
9• Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR°s use oN�v
c�,.., in...�. TOTAL
ine Ltg. Xfmr.
mote Control
� Pool
I hereb certi fhaf I ins ecfed fhe elecfrical
Boom ., ..
on the dates stated
Investigative Fee ; � f1na1 � ,�� A pa ��'��
_ THIS INSTALLATION MAY BE ORDERED QISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.�
OFFICE USE ONLY This request void 18 monfhs From validation date prinfed in fhis box.
IIIII r1
�������������Iluil ����� ��J-a
�����I����������� �,�7
* 0 4 2 6 9 8 1 7� ���—"� �
PLEASE PRINT OR TYPE
Requesf Dafe
� Rough-in inspection required? ❑ Yes o Ins
r � pection Olher ihan RougMn: ❑ Ready Now Will Call
'�%�"'�Jp (You musf call the inspector when ready) Date Ready:
�, �censed contractor ❑ owner hereby request inspection of the above elecfrical work at:
1ob Address �Streef, Box, or Roufe No.�
�� C} p.� � C�ry Zip Code
��� a`�' ��" N� F r i c«e. 5 5"c� 3 Z
Secfion No. Township Name or No. Range No. Fire No. �....,
Occupanf
� � + ir � Phone No.
�erC�. ! � � �—�7� _ 43 3 �
Power Supplier
.. ,---���-..' ..�.°`� Conkacfor License No.
c Master Lic. No. (Plant Elecl
�a-�d I` lec.fr; .-,
Mailing Address (Confracfor or Owner Performing Insfallafion) �� O���O
� Sl I t� v�c� �.�.e.. !U t�c� �,,.d,o ue-�- jyt S� � 0
Authorized Signafure (Conhacfor or Owner Performin� /f 2
\ i�/i ,� A Phone No.
� ��.)���/t►.' 1 � � � r ° � l d�
E���A �$�96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY