P - 78776RE(�UEST FOR ELECTRICAL INSPECTION
� o�- 3 5 5 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800 !
Home uupiex r.pr. o��y. ", ,����
Commercial Industrial Farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
^X" obove the work covered by this request. Enter remarks in this space and on the
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Calculate Inspection Fee - This Inspection Request will not be accepted wifhout fhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic $ig. Above 200 Am s Above 100 Ai
Transformer/Generator INSPECTOR'S USE ONLY �. 3 0 3�, 8' TOT
Sign/Outline Lig. Xfmr.
Alarm/Remote Control
$wimming Pool I hereb cerli that I ins ed the electrical installation described herein on th
Fee
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Irrigation Boom RougMn �--3
Speciallnspection Final � �'���
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DtSCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void �months 6om validation date prinled in ihis box.
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PLEASE PRINT OR TYPE
R est Da�e Rough-in inspeclion required$ ❑ Yes ❑ No Inspecfion O�e� Than RougMn: ❑ Ready Now � W�II Call
�� �,, `� � 3 �You must call the inspector when ready) Date Ready:
I, ❑ licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addiess (Sfreet, x, or le No.) Ciy Z�P �e
�35� ��t �t', l�E , R � � M � - kS� �
Section No. Township Name or No. Range No. Fire No. Couny
Occupant
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�ower Supplier � � Addres
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(Conhacfor or Owner Performing
C�T.d�
Phone No.
?�3 -511- Ss7�
Conkaclor License No.
1 8/�6 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
lic.