P - 79735� REQUEST FOR ELECTRICAL INSPECTION �
`� j�Q Minnesota State Board of Elec[riciry �
O`���+ � � 1821 Universiry Ave., Rm. S-728, St. Paul, MN 55104 � �
Phone (612) 642-080 � �'°�'�
� Home Duplex Apt. Bld . Other � e!b New Addn
� R/rr
r,...,�.,e.,.:..1 I.,,J��.rt..l Fnrm �� � Remad Repair
� "X"
1 Elec Heat ( � Temp. Service �
request ENer remarks in this space and on fhe back of fhe wbife copy
Calculare Inspec�ion Fee - This Inspecfion Reques� will not be occ�}�d withou� /he correct fee:
Other Fee # Service Enfcance Size Fee # Circuits
Mobile Home Park Stali mps o 100 A
Street Ltg./TraHic Sig. Above 200_Amps Above 100
Transkrmer(Genemror �NSPECTOH'S USH ONLY /
Sign/OudineLlg.Xfmr. �/ �u�„?�Q� /H �L��3�"
Alarm/Remote Conhol
� �� 7—i—$'°z`
Swimmin5l Pool ., . .. .� . % , � _. � _ ._�� ._ �___.�_� �...._...
Fee
3�
the dates noted
Dote
2 ��l�C1L
THIS INSTALLATION MAY 8E ORDERED DISCONNECTED IF NOT GOMPLE7ED WITHIN 1S MONTHS.
OFFICE USE ONLY This reqoesf void 18 momhs from validalian dale prinled in ihis 6ox.
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PLEASE PRINT OR TYPE ����
Reqou� Dme Rough-in inspxiion required? Yes ❑ No Inspection Olher Than Rwigh�lm ❑ Reody Now Will Coll
1�a rj � �/ (You mvs� mll �he inspenor whe� readyl Oate Recdy:
I, ❑ licensed conlmctor owner hereby requesf inspection of ihe o6ove elecfrical wark ot:
hb Address (Shcet, w 2ouh No_) Gy 2p Code
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TAT- �S� OPY - SEE INSTRUCTIONS ON BAGK OF. YELIOW COPY . ._..�