P - 80978E
REQUEST FOR ELECTRICAL INSPECTION
s /'�_�57_��� � Minnesota State Board of Electricity ��
U 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us � : '
Home Duplex Apt. Bldg. Other: New Addn
Commercial Intlustrial farm Remod Repair
'r Co ' er Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elect. Heat Temp. Service
'X" above the work covered by this request Enter remarks in this space and on the back of the white copy on/y.
(ti1/LQ, C.e� �` �'l�-
Calculate Ins tion Fee - This lnspection Re uest will not be acce ted wiihout the correct fee.
Other Installations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
7r8nsformer/Generator INSPECTOR'S USE ONLY TOTAI,.�O �J�
Sign / Outline Ltg. Xfmr. d ��
Alarm/Remote Control
Swimming Pool
I hereby certiTy that I inspected the electrical installation describetl herein on the dates stated: �
Irrigation Boom Rough In Date
Speciallnspecti r°'�
Final Dat � .2 P
Investigative Fee Jr—'
THIS INSTALLATION MAY BE ORDERED CONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
M�µMM� �T�.�.TmT�~.�.�T.�.�.Tm OFFICE USE ONLY This:request void 18 monlhs from validation date printed in ihis box.
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Job tld s_($t�; Box, or �GLn Vv, / V` C'ry r� � Z�P Code. ,
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Section No. Township Name or No. Range No. Fire No. County
Occuoant/"_ . Phone No. �
Power
Mailin Address
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Authorized Sian��
Address
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Company or Owner Perfo ing Installation)
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Ftor, Company or Ow er Pertortning Installallon)
No. I Master Lic. No. (PIaM Elect. Only)
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EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY