P - 79782RE(�UEST FOR ELECTRICAL INSPECTION
� 0��, °.� � Q � Minnesota State Board of Electricity s
`� `� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone (612) 642-0800 '�'
Home Duplex Apt. Bldg. Other: � \ New Addn
Commercial Industrial Farm ' ,>5� Remod Re air
Air Cond. Htg. Equi . Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above fhe work covered by this request. fnter remarks in this space and on Ihe back of ihe white copy onJy.
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Calculate Inspection Fee - This Inspection Request will not be accepted wifhout the correct fee:
Other Fee # Service Entrance Size fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/GeneraFor INSPECTOR'S USE ONLY TOTA `�
Sign/Outline Ltg. Xfmr. j j� �L
Alarm/Remote Control
Swimming Pool
I here certi thaf I ins ted the electrical insrollation deuribed herein on the dotes stated
Irrigation Boom RougMn
Special Inspec - � � � 7 �L
Finol Da
Investigative Fee
_ THIS INSTALLATION MAY BE ORDERED DISCO CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void,,8�months from validafion date printed in this box.
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PLEASE PRINT OR TYPE
Request D
� ^O � Rough-in inspecfion required2 es ❑ No Ins fion Ofher Than Rou Mn:
/ Jj P� 9 ❑ Ready Now ill Call
�� (J (You must call the inspector when ready) Dote Ready:
I, ❑ licensed co tractor � owner hereby request inspection of the above electrical work at:
lob reu (Sheet, Box, or Rou P
�� � �p 3 �14+/� �� cIy/�2r���'�'� �3 ��3 Z
Section No. Township Name or�N� Ran� o. Fire No. County
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Occu nt 1 Phone No.7 3 S 2
O hJ � (�t1 I� ,�'D c✓t�J Co ( 2 24Q— `i�S`2 S" �..el/
Power Supplier Addreu
�CG�e� �, i,�' N�-�. �1�
Electriml Conhacfor (Compon Name� •? Conhaclor License No. Master Lic. No. (Wanf Eleci. Only)
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Mailing A res � o r o ner Performina Installatiail
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY