P - 79634. RE(�UEST FOF� ELECTRICAL INSPECTION �
8 fl )���� � Minnesota State Board of Electricity
dJ L 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone (612) 642-08 `'�'
ome Duplex Apt. Bldg. Other: �71 New Addn
Commercial Industrial Farm ' v emod Re oir
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will rot be accepted withou► the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Sfall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. �r,+�xr��/ 2��"`� 2 9��� /� �
Alarm/Remote Confrol �
Swimming Pool � ��1e'd c�/S��— Q 2
I here certi ihaf I ins fhe electrical insfallafion descri
Irrigation Boom R�9�� Da�e
Special Inspection '�� � � Z ��'
Final � Dafe
Investigotive Fee JG r/��e (� �} ' Z 9' ° 3
THIS INSTALLATION MAY BE ORDERED DISCONNECTED F NOT COMPLETED WITHIN 18 MONTHS.
OFFICE U8E ONLY This reque3f void 18 monlhs (rom validation daTe printed in this box.
I��I� I���� ���II II��� ����� ����� �����I�III �� �� ��`1��� 2 9�'� i
* 0 8 0 2 3 0 6 1* y���5�1
PLEASE PRINT OR TYPE
Requesf Date Rough-in inspection required? Yes ❑ No Inspecfion Olher Than RougMn: Ready Now 0 Will Call
� p��f Q� (You must call the inspector when ready� Date Ready:
I, ❑ licensed contractor�owner hereby request inspection of the above electricai work at:
Job Addr�r,r{S� „�ox, o Route No� Ciy �� Zip C�e��� `
�� 1 / �... 3
�l aC O� ( �� � S v�
$ecfion No_ Townshio Name or Alo_ Ra�we No_ Fire No. County
0
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(Conkactor or Owner Performing Insbllafion)
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Phone No.
`�6 � -57�i-1$� 5
J�3��►.5►,`t
J
y
or Owner Perfwming Insfallation) Phone No.
� �63 -5? � t�b5
S TE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY