P - 77734�02-395
Commercial
Air Cond.
Dryer
"X" above the �
Industrial
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave. Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0 Or ��
Apt. Bldg. Other:/ }7 �, �` New Addn
Farm f�` V �7�-� Remod Re ir
Water Hh. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of the white copy only.
Calculafe Inspec►ion Fee - This Inspeciion Request will not e accepted without the correct fee:
Other Fee # Service Entra ize ,F�ee # Circuits/Feeders
Mobile Home Park Stall l� 0 t 0 ��- to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s F
Transformer/Generator INSPECTOR'S USE ONLY TOT,
Sign/Outline Ltg. Xfmr.
Alarm/Remote Conir ' ,. r`.
Ree
Swimming Pool C�reb certi that I ins ed e elechical installafion descrir`bed�erein on the dat - O�
Irrigation Boom RougMn Dar�,
Special Inspection � �> - �"- ?�_03
Final Dafe `
Imestigafive Fee � �t !!1 �L
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHI 1 ONTHS.
OF�ICE USE f�jJLY This request void�8'monfhs from validafion dafe printed in this box.
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* 0 8 0 2 3 9 5 4* � i�`' �� /
PLEASE PRINT OR TYPE
Reques Daqte Rough-in inspeclion required? �es ❑ No Inspecfion 01her Than RougMn: ❑ Ready Now ❑ Will Call
/-� Z �� .� (You must call fhe inspecfor when ready� Date Ready:
v
I, ❑ licensed conhactor owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or Route No.) Ciy Zip Code
6// 6srNE ���� � z
Section No. Township Name or No. Range No. Fire No. Coun
3 0 �- d l��i
Occupant � Phone No.
�s � v G 3- S7 - S
Power Supplier Address
�e �L 1�`l. s � �l ✓
Elechical Contrador (Company Name) � � �^ Conhador License No. Masier Lic. No. (Plant Elecf. Only)
� � l
_! �w � �
Mailing Address (Conhacfor or Owner Performing InsfallaKon�
S
Aufhori cd SiandOre IConhacfor or O�vner PerForminq Ins�allation) Phone No.
` � � ?6 3 57/-
�`�---,�
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY