P - 79737. REQUEST FDR ELECTRICAL INSPECTION
� o� �� Q'� � Minnesota State Board of Electricity `:a
V 1821 University Ave., Rm. S-128, St. Paul, MN 55104
�� Phone(612)642-0800
Home Duplex Apt. Bldg. Other: � m � New Addn
Commercial Industrial Farm KJ� ` Remod Re air
Air Cond. Htg. Equip. Water Hir. Load Mgm ther:� �� �� I��
Dryer Range Elec. Heat Temp. Service ��i
"X" above the work covered by this request. Enter remarks in this space and on the back of the whiie copy only.
Calculate Inspeciion Fee - This Inspecfion Request will noi be accepted withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps �� �
$heet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL,/�/
Sign/Outline Ltg. Xfmr. / � /
Alarm/Remote Confrol
Swimrning Pool
I hereb certi that I ins fhe elechical i stallafion described herein on ihe dafes stated
Irrigation Boom 1 Rou Mn Da
Specia) Inspection
9 - -a
Final
Investigative Fee � � J
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 ONTHS.
OFFICE USE ONLY This request void y6 monfhs from validation date,printed in this box.
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* 0 8 0 2 3 8 1 4* 'e� 1l ��/ J!�
PLEASE PRINT OR TYPE �T�
Request Dafe Rough-in inspection required2 � Yes ❑ No Inspeclion Olher Than Rouglrin: ❑ Ready Now Will Call
� —�� — Q� (You must call the inspecror when ready� Date Ready:
I, ❑ licensed contractor � owner hereby request inspection of the above electrical work at:
Job Address �Street, Box, or Route No.) City Zip Code
� � �{,Z MD/✓RO L- S T �l��OLE' `.�.54�.3 �
Secfion No. Township Name y,N� . Range Nq� p fire No. Counly
,� _, °� � /9NGirfi
Occupant Phone No. ,
��� �Zf�/IC�G , G�,� - 7$�- 4�$7/
Power Supplier Address �
�C'-C'� ^�joLS, �/o, D/�%
�Elechical Contracror �Company Nome) Contractw License No. Masper Lic. No. �Plant Eled. Only)
� '> G�/ /�iG�/�
ig Address �Conhacfor or Owner Performing Insfallafion)
s/1� Nt L
rized =' �Conhactor or Owner PerFormin Instaltation)
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�Ol A-1 1 8/96 STATE BOARD COPY - SEE
No.
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