P - 79964�02-288 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Slate Board of Eleciricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
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�I Indushial - Form fi O CYi SCi Re
Htg. Equip. " ater Hh.
- Range Elec Heat
work mvered by this requesR Enler
Mgmt. - O�her: `
Senice
in fhis space and on
Calcula�e Inspecfion Fee - This lnspection Reques� will not be accepfed withoN Ihe correcf fee:
O[her Fee # Service Entrance 5' e Fee k Circuits
Mobile Home Park Stall 0 to 00 Amps 0 to 100 A
Sfreef Ug./Tmffic Sig. Above 200 Amps Above 100
Transformer/Generotor INSPECTOR'S USE ONLV
Sicm/Oufline L�p. Xfmr. � �
C�197
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Addn
Fee
CO, S�
$wimming Poo� 'V J �: I hereb ce�f �har I ins ecied �he eleanml tnnalla�ton descn -r✓��e �6aies,siam8 ���
Irrigation Raugh�ln Doy
Special Inspechon ' '6� ' / � �^ �/
r�ai � ° Z q � a
Invesligafive Fee
THIS INSTALLATION MAY BE ORDERED DISC C ED IF NOT COMPLETED WITHIN 18 MONTHS.
I� I� II I�IIII�I II�I III�I II III IIIII IIIII � OFFICE USE ONLY This reqvesf void 18 momhs from validalion dare prinled in ihis box.
* 0 8 0 2 2 g 8 1� I I�I �, G1i �J�%
86�50
PLEASE PRINT OR TYPE
� � �O� ('� Raigh-in inspxnon required2 ❑ yes ❑ No Inspection O�her Than RwgMn: ❑ kendy Now � WIII CaN
1� ��l �� lYoo m� nor when readYl Dare Revdy
I, ❑ Iicensed conlmcfor ❑ own f inspection of the above elechical woik at:
lob Addresz (Street, Box, o� Rouk No.) Ciry Zi Code
s� I �l �T� ��D t-F- S�43Z
Section No. Township Nome or No. Range No. , Fire No. Coonry
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id�V �� M.C�
Canrcy brt or Owner Per(o�mi�g Ins�ollafian�
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ne (Commc�or or Own Pedo ing Insmllanon�
76 �
ATE BOAPO COPY - SEE
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