P - 79900' REQUEST FOR ELECTRICAL INSPECTION
Q�{ °� �'J �� � Minnesota State Board of Electri '
V�J L J 1521 University Ave., Rm. S-128�tt��,�If�5104
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. Other: �[,��y�
Dryer Range Elec. Heat Temp. Service � �t a(e.�
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy oniy. �
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Calculate Inspection Fee - This Inspection Request will not be accep►ed without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./TrafFic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY ,,, (� /- TOTAL
Sign/Outline Ltg. Xfmr. �� /-C�''1 �� t �
Alarm/Remote Conhol ���
Swimming Pool
. e erti tlwt ! ins e elechical ' stallation dexribed herein on the dates sMted
Irrigation Boom F,.i„ par�
Special Inspection � � l�— G�"�
Final G
Investigative Fee
_ THIS_INSTALLATIQN MAY BE ORDERED DlSCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months From validation date printed in ihis box.
I{I�{ II III II I�I II flf II Ilf II I1I II III II III II �+.�b � 2 9 r,
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* 0 8 0 2 3 3 2?� a/. 50
PLEASE PRINT OR TYPE
� Request Dafe Rou h-in in ction r uired$ Yes
9 We eq ❑ ❑ No Inspeclion Other Than Rough-In: ❑ Ready Now � Will Call
�You musf call the inspector when ready� Date Ready:
I, ❑ licensed contractor �owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Roufe No.� City Zip Code
(o s[� S 1-c�.c:.o`. La.•.A.- �r- � d�- s 5�`3 Z
Section No. Township Name or No. Range No. Fire No. ounty
� �
Occupant n Phone No.
Power
Master Lic. No.
Address (Conhactor or Owner Performing Installation)
or Owner Performing InstallaKo�� Phone No.
� �^T� �1�03 S'1 ► —
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY