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*03920915*
REQUEST FOR ELECTRICAL INSPECTION �,���
Minnesota State Board of Electricity �'�
1821 University Ave., Rm. 5-128, St Paul, MN 55104 ����
Phone (612) 642-0800 �`'^'-�
Home �uplex Apt Bldg. Other New Addn
Commercial Industrial Farm Remod ReRair
Air Cond. Htg. Equip. 4Vater Htr. X Load Mgmt. Other.
Dryer Range Elec. Heat emp. Service
"X" above the work covered by this reques[ Enter remarks in this y�ace and on [he back of the white ccpy oNy.
SFVEk'S ��WITCH INSTALLATiON
Calculate In,pecbbn Fee - This Inspection Request will not 6e accepted without fhe covect /ee:
Olher Pee s+ Service Entrance Size Fee +� Circuits/Feetlers Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street LtgJTraffic Sig. Above 200_Amps Above 100 Amps
TransformeNGenerator INSPECTOR'S USE ONLV TOTA
Sign/Outline Ltg. Xfmr. � S�
Alarm/Remote Control
Swimming I hsrsby cerUfy iM1at I inspac�ed [he elechical Installa�ion desai�etl herein on roe tlates sta�etl
Irrigation Ho �� aouqn-m oate
h Special Inspection 1' . :J� �
Fnal � � �Gt
Investigative Fee � — "Z
THIS INSTALLATION MAV BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 NiHS.
OFFICE USE ONLY This reques[ witl 18 moMhs trom valitlation date prin�etl in fiis boz.
392-09�,5] � �a65- �
3�f3 ,YUMB::z 115UC�E,L?:,`v.i
PLEASE PRINT OR TYPE
Reques��a Rougii-inlnspecM1Onrequirsd7 �Yes [�tJo IrispectianOlherThanRaugh-�n�. f.Y ReadyNOw O Wi1lGall
_ igD4/38 �t �t
�1'ou mus[ cell Ihe inspecNr wher reatly) �ate Ready q � „ _
I, "� liaensed contractor ❑ owner here6y request 'mspection of the above electrical work at:
Job Address (Streo�, BoK or Raute No.l City Zip Gode
115861 WA��HINGTUN ST NE FFiIilLEY SS�l3�
Sedan No_ Tow�blp Name cr No. Range Na Flre Na Gmnty
ANOKA
Occupan� Phone No.
:RO@ERT L MOREN 57I—+�67�
Pawer Suppller Atltlmss
NSP "tFi.:} tIFFTCE
Elechical GonVactor (Company Name) Conhacfor �icense No_ Mastar Gc No. (Plant Elact Oaly)
T ('" _
Malling Prldress �GOnVacror or Owner Periwmirg Installation)
� _ ' f�'
Authonzetl SlgnaWre (�nVactor or Owrier Pedorming Installationl (,`'1 .♦ ^ Phone No-
v[7N
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EB-0p001A- ei95 STATE BOAPO COPY - SEE INSTRIICTIONS ON eACK OF VELLOW COVV