P - 79878R:���340 �
�( Home Duplex
Commercial Industrial
Air Cond. Htg. Equi
Dryer Ronge
"X" above the work cover d b
�Oy+G -2-�C�%
� REi�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 =
Phone(612)642-0800 "�'
. Blda. Other: New Addn
Farm emoc
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
�quest. Enter remarks in this space and on the back of the white copy
���z.c . �nre � �a��
Caiculate inspection Fee - This Inspection Request will not be accepted without fhe correct fee:
Other Fee # Se ' ntrance Si Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 0 200 ps 1 � 0 to 100 Amps
Sheet Ltg.JTraffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT .(f C%
Sign/Oudine Ltg. Xfmr. �i Q(.� ��
Alarm/Remote Control e� V V �
c
Swimming Pool
I hereb certi that I ins the elechical installafion described herein on the
Irrigation Boom Rough-lo Da
Special Inspection `�'� �^ a� � �
Final y��
Investigative Fee -.�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED {F NOT COMPLETED ITHI 18 MONTHS.
. OFFlCE USE ONLV This request void 18 months 6om validotion dote priMed in this box.
I{IIIIIIIIIIIIIII{IIIIII{IIIIIiINII{II{IIIIIIi�I � ��
*08023400* 296`�� S!/,SO
PLEASE PRINT OR TYPE
Request Date Rou h-in ins on r uired? ❑ Yes
g pecfi eq ❑ No Inspeclion Olher Than RougMn: ❑ Ready Now � Will Call
(You musf mll the insQector when ready) Date Ready:
I, ❑ licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Ad�reu (Streef, Box, or Roule No.) City Zip Code
5019/ �7��''rtiN Sr �tJLs �ivr-�y �5�3 Z
$ecfion No. Township Name or No. Range No. Fire No. County
Occupant Phone No.
�o� �3-5'3!- ��
onhacror (Company Name) I Conhoctor License No. I Master Lic. No. �Plant
dress (Conhactor or Owaer Parformiag Installation�
Signature (Conhacror or Owner Performing Insiallafion) Phone No.
11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY