P - 79838REQUEST FOR ELECTRICAL INSPECTION
8� ��/� � Minnesota State Board of Electricity
`-+ 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� 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. iher:
Dryer Range Elec. Heat Temp. Service ;�c} (�2.�( � Ot�.� 1„�i
"X" above the work covered by this request. Enter remarks in Ihis space and on the back of the white copy only.
Calculate Inspection Fee - This Inspecfion Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Cir ' eeders Fee
Mobile Home Park Stall to 200 Amps 0 to 00 mps
Street Ltg./Traffic Sig. Above 200 Am s Above 00 Amps
Transformer/Generator • INSPECTOR'�S USE ONLY T TAL �
Sign/Outline Ltg. Xfmr. � ��
Alarm/Remote Confrol
Swimmin Pool � Z_
9 I hereb certi fhat I ins fed eclrical installation described herein on stded��
Irrigation Boom RougMn i� d�
Special Inspection
Final Da ���
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation dafe prinfed in this box.
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PLEASE PRINT OR TYPE
Requesf fe Rough-in inspecfion required2 es ❑ No Inspeclion Other Than RougMn: ❑ Ready Now �II Call .
3� rOO� �You musf call ihe inspecfor when ready) Dafe Ready:
I, ❑ licensed contractor�owner hereby request inspection of the above elechical work at:
Job Address (Skeef, Box, or te'No.) Ci Zip Code
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Seclion o. To shi Name or No. ., _ Ran e No Fire No. C un
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nhaMor (Company Name)
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1 8/96 I
STATE BOARD
Phone No.
?63-57 -
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- �'?63 �57�(-
- SEE INSTRUCTIONS ON BACK OF YELLOW COPY