P - 77209REGIUEST FOR ELECTRICAL INSPECTION -�
tQ (� ��� S Q Minnesota State Board of Electricity
� v `� 1821 University Ave., Rm. S-128, t. Pay�, MN 55104
Phone (612) 642-0800 � � � "
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Home Duplex Apt. Bldg. Other: � New Addn
Commercial Industrial Farm ��3. Y� Remod Re air
Air Cond. Htg. Equip. Water Hir. Load Mgmt. her:
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 only.
Calculate Inspection Fee - This Inspection Request will not 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
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY E� TOTAL �
Sign/Outline Lfg. XEmr. ���„r4'f` �-c� pK'�
Alarm/Remote CQnfrol /.E"G — C A.(J
Swimming P '�
I hereb certi thaf I ins ected fhe elecfrical installation described herein on the dafes stated
Irri9ation Boom RougMn pa�e
Special Inspection
Final / Date � 4
Investigative Fee �f�- �c.�— /a ��, — O s
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHI ONTHS.
"- � OFFICE USE ONLY This requesf void 18 months from validafion dafe printed in this box.
I II�) II II) II I�I II III II III II III II III II III �� III I IIII , i l / .S'�
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PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required? Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now ill Call
�. Z. 3• � Z (You musf call the inspector when ready) Dafe Ready:
I, ❑ licensed contractor owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or Rouffi No.) City Zip Code
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Section No. Township Name or No. Range No. fire No. Cou
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���P°^� 2� 5 � 9 Phone No.
Power Supplier �a Address � �� '� �
�u�.-� IM� 1 �a � � .
Elechical Conhacfor �Company Name� Conhactor License No. Masler Lic. No. �Planf Elecf. Only)
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Mailing Address (Conhactor or Owner Performing Installafion)
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Aufhorized Signature (Conha or Owner Pe rmi stallafion� Phone No.
76�-� ��
E&0 1 1 8 96 S E ARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY