P - 79738OO�°38O �
RE(]UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Pa I, MN 55104
Phone (612) 642-0 00 � �
u' Home Duplex Apt. Bldg. Other./ �� �\ New
Commercial Industrial Farm /� L SV emoc
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy
��...
�_.
Addn
3008�
Calculaie lnspection Fee - This Inspection Request will noi be accepted 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
Sireet Lfg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR•s use qNLY n TOTAL /d
Sign/Oudine Ltg. Xfmr. �dC(f-�/2 C-�G`vt� �/
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins fhe electric installafion described herein on the dates slafed
Irrigation Boom RougMn D
Special inspection � 3^E
Firwl _ GT
Investigative Fee ,,,c{ �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void onths 6om validation date printed in this box.
IIIIIIIIIIIIilllllllllllllllllllllilllll�llilllll '� � ���� ��
* 0 8 0 2 3 8 0 6* �� ��
PLEASE PRINT OR TYPE
Requesf Date Rou h-in ins ion r uired? Yes
2^ ' O g pecY eq ' ❑ No Inspection Other Than Rough-In: ❑ Ready Now ill Call
2� �� �You must call the inspecror when ready� Dafe Ready:
I, ❑ licensed controctor L� owner hereby request inspection of the above elechical work at:
Job� d�s� eef, Box: or Roufe No.��� ��' City � � Zip Code �
��,-e:c,�... v- � �
Secfion No. Township Name or No. Ranae No. Fire No. CounN _
�� ���
�i�a�
r
ontrac or ,Company Name)
�N / `'C�
dress �Conhacfor or Owner Performing
SQ.M e.,�
SignaNre �Confracto r Owner P r
� 8�96 STATE BOA
I ' �a �
Phone No.
ik-- ' � 3 780 �'3Z
Address +1
' h Q t,c� � . �W ,
onhacror License No. Masler lic. No. (Plant Elect. Only)
tallafion�
g Instal�pti � Phone No.
� 3 �eo q3
i OPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY