P - 79877REQUEST FOR ELECTRICAL INSPECTION °'E
8(.� � o�� Q � Minnesota State Board of Electricity
v �� 1821 University Ave., Rm. S-128, St. Paul, MN 5510A -
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re 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 �his space and on the back of ihe white copy only.
Calculate Inspecfion Fee - This Inspection Requesf will not be accepfed withouf 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./TraEfic $ig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T L
Sign/Outline Ltg. Xfmr. � �'� 1 '�°pOL •�
Alarm/Remote Confrol •'�} Q � 1 � �
Swimming Pool � �� v �%�
I hereb certi that I ins the eleclrical installafion described herein on the dafes`
Irriaation Boom p,..�w�.. �i n..b a
Investigative Fee �--�� G� — T�, �
THIS INSTALLATION MAY BE ORDERED QISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months 6om validotion dafe prinfed. in fhis box.
Ifiillllllillllllffllllllllffllillillllllillllllil �e�3q�! p.
* 0 8 0 2 3 3 9 2* �i9��`.�
PLEASE PRINT OR TYPE '�� SZ�
Reqvest Date Rough-in inspec�ion required$ ❑ Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now �Will Call
� (You must call the inspecfor when ready� Date Ready:
I, ❑ licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address (Sheef, Box, or Roufe No.� Ci Zip Code
t40 f� r�c�,rcl�-�� C� �'n. d.� �'-t3z.
Secfion No. Township Name or No, Range No. Fire No. nly .
Occupanf �O� Z Phone No.
t2��,r�,r °t to 3- 51 Z.-9 � 2y
Power Su ier Address
�Conkactor or Owner Performing Insfallalion)
or Owner
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY