P - 78613RE(�UEST FOR ELECTRICAL INSPECTION
8 0����J � Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 ,� '��
Home Duplex Apt. Bldg. Other: � New Addn
Commercial Industrial Farm � Remod Re air
Air Cond. Htg. Equip. Water Hh. Load Mgmt. Ot r:
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 not be accepted withoui ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stoll 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. Xfmc S�W,,I"rL '�'3�� � °R"
Alarm/Remote Control /�-'`��"y���` �� ,��
SwimmingPool —_ � ��-- :�0�
I hereb cerli �af I ins fhe el ical installafion descri , e� on the�'dates s�
irrigation Boom � � Roo9h-lo Dp�e
Special Inspection �
Final � pu
Investigative Fee Z —G
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONT S.
OFFICE USE ONLY This request void l�monlhs 6an validation date printed in this box.
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PLEASE PRINT OR NPE �-' L/
Requesf Date Rough-in inspeclion required? Yes ❑ No Inspection Ofher Than RougMn: ❑ Reody Now Will Call
Z � f Q 3 (You must call the inspector when ready) Date Ready:
I, ❑ licensed contractor �owner hereby request inspection of the above electrical work at:
Job Address �Skeer, Box, or Route No.) Ciy Zip Code
�o t S'�', VU � � � �c� �'e- SS �
$ection No. Township Name or yQ. Rang�� Fire No. Coun
CJ .� {/��
Occupant�� .. ! ,) � Phone No.
a� N�l��^-to lolZ-Z�7-S7q
Power Supplier Address
� � �L.�S a2�'-�l 0 t ��
Elechical Conha Company Name) Conhacfor License No. Masfer Lic. No. �Planf Elecf. Only)
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Mailing Address (Conhacfor or Owner Performirg Installafion�
5��.� �s �v b
AWhorized Si nk r Own Performing Insfallation) Phone No.
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EB-OOOOlA-1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY