P - 79508REGIUEST FOFi ELECTRICAL INSPECTION -
S������ � Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
• Phone (612) 642-0800 �
Home Duplex Apt. Bldg. Other: Addn
Commercial Industrial Farm Remod Re air
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 Inspecfion Fee - This Inspection Request will not be accep►ed without ihe correct fee:
Other Fee # rvice Entrance Size Fee Circuits/Feeders e
Mobile Home Park Stall 0 to 200 Amps to 100 Amps
Street Ltg./Tra(fic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator �NSPeCroR's usE ON�r TOTAL�� /0
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Conhol 2 9 5 8 �3
Swimming Pool '
I hereb cerli tliat I ins the electri I installation described herein on the dates stated
Irrigation Boom Rougffln � /� d,.�
Special Inspecfion �
Final �y�'
Investigative Fee ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months From validation date printed in ihis box.
III�I(IIIlilllilllll(IIIIIIIIIIIIN����l�l a��
* 0 8 0 2 3 2 6 9* �� �? S--
LEASE PRINT OR TYPE
Request Da Rough-in inspecFion requiredZ ❑ Yes No Inspecfion Other Than. RougMn: ❑ Ready Now Will Call
�pZ- 6� �You must call the inspeclor when ready) Dafe Ready:
I, ❑ licensed contractor ow�er hereby request inspection of the above electrical wosk at:
Job Address (Sheef, Box, or Roufe No.� Gty � Zip Code �("'�+1j
��f�3 ��� � ��� ��� d I� �T�
Secfion No. Township Name GFNo. Range No. Fire No. County ��
c,JCJ �
Occupanr q� ' Phone No.
�I i � � V �S a-v� /ol- 5�l- �i�`�7
Power Sup lier Address � /�����, `"'_ �_ '.
Elechical Conhactor (Company Name) Conhacfor License No. Masfer Lic. No. (Planf Eletf. Only)
D ��
Mailing Address (Contracror or Owner Performing Installalion)
e� ing Installation� Phona No.
�-7s� �03q
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY