P - 79371ry REQUES7 FOR ELECTRICAL INSPECTION ,��:"���
� O G- 3 6 9� Minnesota State Board of Elechiciry � ��
7821 University Ave., Rm. 5-128, St. Paul, MN 55104 �� •'
• Phone (612) 642-0800 ��� �
Home
New
Water Htr. Load Mgmt Ofher.
Elec. Heat Temp. Service
requesL Enter remarks in �his space ond on fhe back of the whi/e capy
Caiculaie lnspec/ion Fee - This Inspecfion Requesl will not be accepfed wifhoul fhe correcf /ee:
Other Fee # Service Enhance Size Fee N Cirtuifs/Feeders Fee
Mobile Home Park Stail 0 to 200 Amps 0 to 100 Amps
Sireef Llg./TraHic Sig. Above 2W—Am s Above 100_Amps
Tmnsformer/Generalor INSPECTOH'S USE ONLY TOT
Sign/Oudi�e Ltg. Xfmr. �� �� J G� S- �
Alarm/Remote Control
3��;j /.SU
Swimming Pool � here �en� iha� �'��.pecr d ihe el�o-�cal memllai�o� described here�� o� Me dare: xmrd
Irrigo�ion Boom Raugh-In Doy/ ,
Speciaf InspeUion � —�
F��al �/_ /!` G..
Invesfigafive Fee �—
THIS INSTALLATION MAV BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request voi monllis fmm volidafian dare printed in �his box.
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PLEASE PRINT OR TYPE
Reques� Daa RougMn inspenion required2 Yes ❑ No Inspectton O�her ihan kough-In: ❑ Ready Now Will Cdl
�� � 02 �You man mll Me inspecbr when reody� pare Ready:
I, ❑ licensed conlrociar � owner hereby request inspection oF ifie above electrical work at:
Mb Address (SVee�, Boz, or Rouk No.) Ciy Zip Code
1038� /afxTEW2 ST. f�,�, �21Dt,�Y 55`F3'Z
Setlion No. Townshlp IJome or No. Ra�n�gpe ,Neo�.._ Fire Nn Couny
� � C. �1�[ ] ; �.. AI�l01CA
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