P - 84761RE�UEST FOR ELECTRICAL INSPECTION
`�F 4�- 2 7 6 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 =
Phone (612) 642-0800
K Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod e 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.
Ne� �..ut.�vq.c �
Calculate Inspection Fee - This Inspeciion Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 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
,.. ,.. .�. .. .,� /c d��
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins ected the elechical installation described herein on the dates stated
Irrigation Boom Rough-In Dor�
Special Inspec
Final pateo � . Y/
Investigative fe � p
THIS INSTALLATION MAY BE ORDERED DISC ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This req�est void 18 months from validafion date printed in this box.
� ���� �� ��� �� I�I 0 ��� �� ��� �I ��� �� ��� �� ��� � �I�I ����-� •�-��
* � 4 4 1 2 7 Ea 3�K PLEASE PRINT OR TYPE
Requesf Dafe � Rough-in inspection required? ❑ Yes No Inspection Ofher Than RougMn: �Ready Now ❑ Will Call
a, — r� � g� (You must call fhe inspector when reody) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Shee Box, or Roufe No.) .Cify Zip Code
�3a �3 �°� /�-� e . ,� . �� ��� �s y�a
Secfion No. Township Name or No. Range No. Fire No. County
/�� /� �
Occupant . Phone No.
�' ti 62'� 6Q e.e% ?8D --.t"9 02 9
Power Supplier �- . Address
7 "� �G� �/�!C I G� �% �P � I
(Conhacto/rJ or Owner Perform�ing Instal/laJtion)
! li�J/ W��I �C ��c.�i `�l.- �'i///� ����/
dure ICvnfrador or Orvner Performina Installationl� Phone No.
STATE BOARD�6PY - SEE INSTRUCTIONS bN B/(CK OF YELLOW COPY