P - 78573� ` RE(�UEST FOR ELECTRICAL INSPECTION
C� �� o�� C � Minnesota State Board of Electricity
C� � 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612)642-0800
Home Duplex Apt. Bldg. Other: `Sb 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 this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 ro 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY ,, TOTA C�
Sign/Outline Ltg. Xfmr. �jL�t.� � G�i�g'K.� d
.
Alarm/Remote I
Swimming Pool
I hereb certi fhat I in il�e elechical ' allafion described herein on the dates stated
Irrigation Boom Rough-lo 0
Special Inspection
Final �
Investigative Fee _ 3
THIS INSTALLATION MAY BE ORDERED DIS ED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void�months (rom validation date printed in this box.
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* 0 8 0 2 3 9 6 2* � ��5v
PLEASE PRINT OR TYPE
Request�ple Rough-in inspecfion required? Yes ❑ No Inspection Ofher Than Rough-In: ❑ Ready Now Will Call
C ��� ��. (You must call the inspector when ready) Date Ready:
I, ❑ license contractor � owner hereby request inspection of the above electrical work at:
Job Address (Sheei, Box, or Roufe No.) City Zip Code
20� kuGa S�'" �vC� Fr�+O�Ey ssti3a.
Seclion No. Township Name or No. Range No. Fire No. County
� a ��oka
Occupanf � O Phone No.
�,�rna� ,awr� ��3-7s�-ss� �
Power Supplie Addre
�L Ls o �,�.
Electricol Conkactor IComoanvRlamel Conhacfor License No. Masfer Lic. No. �Planf Elecf. Only)
Mailing Address (Conhactor or
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY