P - 77199REGIUEST FOR ELECTRICAL INSPECTION
Q 0 L= 3 2 3 Minnes'bta State'Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone(612)642- 800 '
Home Duplex Apt. Bldg. Othe : O �.,�p�J New Addn
Commercial Industrial Farm kJ � �� � 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 this space and on the back of ihe white copy only.
Calcvlate Inspection Fee - This Inspection Request will noi be accepted without the correci 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 $ig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. y� �
Alarm/Remote Conhol •� 4 � �� (f
$wimming Pool
�r v tl
yi4, : I hereb certi fhat I ins cted the electrical installafion described herein on the dates stated
, ;; Irrigation Boom Roegh-ln � par _
� Special Inspection � '� 3 � ° Z''z`
Final � � �! ^ Date ,( 6 .
Investigative Fee J� j2�,,,�� �., � 3,
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NO COMPLETED WITHIN.18 MONTHS.
OFFICE USE ONLY This requesf void 18 monlfis from validafion date prinfed in this box.
I IIII II II) II III II III II III �I III II III II III II � I IIII
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PLEASE PRINT OR TYPE
Request Dafe Rou h-in ins fion r uired$ es
g pec eq �' ❑ No Inspection O�her Than Rough-In: ❑ Ready Now ❑ Will Call
�� � D (You musf call ihe inspector when ready) Date Ready:
I, ❑ licensed co�tractor � owner hereby request inspection of the above electrical work at:
Job Address �Sheef, Box, or Roufe No. City Zip Code
5�3o d,���-�. �uc �Q�o1 55� � 2,
Secfion No. Township Name or No. Range No. Fire No. Coun
� v,�
Occupant Phona No.
06� � f/ll��l' G'/2 g2�� 2.�'3
Power Supplier Address
Elech'ca�haclor mpony N vL(//7�!'- Conhador License No. fvlaster Lic. No. (Planf Elect. Only)
,�/Lf �/Y7�'
Mailing Address �Conhactor or Owner Performing Installation)
.5'3c.� �►�e�' ti'� r"�G2 �1I �
Authorized S' nature (Conhocror er Performing Installation) Phone No.
� �'lZ 3.20��
E A-11 8/96 STATE BOARD COPY - SEE INSTRUCTONS ON BACK OF YEL�OW COpv