1104 Diffley Rd - Electrical Permits
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I?1 licensed contractor ?owner hereby request inspection of a6ove electrical work Af:
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Job Atltlress (5[ree6 Box or Po e No.) Cily
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Seclion No. Township Nama or No. Range No. Counry
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PowerSUpplie Atltlress
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ElecMCal C nlrador (Company Name) Conlraclors license No.
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Mailing Atltlr s(COnVacmr or Owner Making Installation) ?
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MINNESOTA STATE BOARD OF ELECTRICITY THIS INSPECTION REQUEST WILI NO7
Grlgps-Mldwey Bltlg. - Room 5-128 BE ACCEPTED eY THE STATE BOARD
1821 Universlly Ave., St. Paul, MN 5510i IINLESS PROPER INSPECTION FEE I$
Phone(81Y)64P-OB00 ENCLOSED. '
REQUEST FOR ELECTRICAL INSPECTION EB.oop°i.o9Q
003 3 3 3? Sae instroclions lor completing [his form on back of yellow capy. /???j??/ ?
a.? fr(p "X" Below Work Covered by This Request
e Add Rep. Type of Building ApplMnces VOlred Equipment Wired
Home Range Temporary Service
Duplex Water Heater Electric Heatin
Apt. Building Dryer Load Management
Comm./Industrial furnace Other S eciy)
Farm Air Conditionar
Otner(speciry) ConVaclors Remarks:
Compute Inspection Fee Below:
# Other Fae # Service Entrance Size Fes # Circuits/Feeders Fee
Swimming Pool 0 to 200 Amps 0 to 700 Amps
Transformers Above 200 Amps Above 100 -Am s
SIgfIS Inspectors Use Only: . SO TOTAL
Irrigation Booms (l(J 14
0
S ecial Inspection ?IJ '
1
Alarm/Communication THIS INSTALLATION MA 10E RE DI CQNNECTED IF NOT
Other Fee COMPLETED WRHIN 18 M
I, the Electrical Inspecror, hereby
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OFFICE USE ONLY ?
This reque3t v0id 18 months hom