P - 79730REQUEST FOR ELECTRICAL INSPECTION
�(4� �'S �, 2 9 9� Minnesota State Board of Electricity �
�� L 1821 University Ave., Rm. S-128, St. Paul, MN 55104
�
' Phone (612) 642-0 0
Home Duplex Apt. Bldg. Other: � New Addn
Commercial Industrial Farm ` � emod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enter remarks in �his space and on the back of the whiie copy only.
Calcula►e Inspection Fee - This Inspection Reques► will not be accepted wiihou► ►he correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA ��
Sign/Oudine Ltg. Xfinr.
AlarmjRemote Co
Swimming Pool - �
I heieb ceAi that I ins the elechical ins tion described herein on the dates staled
�[f19OfIOR BOOfY1 RougMn � Dofe
Special lnspeciion �
Investigative Fee � j� 5� �2 �� �� �% 2� G�—
THIS INSTALLATION MAY BE ORDERED DISCONNECTE IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date prinfed in this box.
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PLEASE PRINT OR TYP� �/�D
Requesf Daf� ��� Rou F�in ins on uired? Yes
Ig pecti req ❑ No Inspection Other Than RougMn: ❑ Ready Now Will Call
� (Yau must call tha i�spector when ready� Date Ready:
I, ❑ licensed contracror owner hereby request inspection of the above electrical work ot:
,ob addreu,s �, s�X, � Ro�re n cry G 7 P Z'�,SY'3o�
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SecYion No. Township Na or o. Ran e No Fire No. Counly
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Occu n !� V / t/ � / Y �—���'"V
(Company
or Owner
or Owye(Perfofning InsMllafjon) , A// J Phone
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ON BACK OF YELLOW COPY