P - 79370RE�UEST FOR ELECTRICAL INSPECTION �,i'� `�
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Ro ry-�� O Minnesota State Board of Electricity �4� ��
G 1821 Universiry Ave., Rm. 5-728, SL Paul, MN 55104
Phone (612) 642-0 --`
Home Duplex Apt. Bldg. Ot �� f New Addn
Commercial Indushial Farm r 7U � Remad Re air
Air Cond. Hfg. Equip. Water Hfr. Load Mgmt Othec
Dryer Range Elec. Heal Temp. Service
"X" obove fhe work covered 6y fhis request Enter remarks in rhis tpace and on the back of the whi/e copy onfy.
Colculate Inspecfion Fee - This Inspection Requesf will not be accepted withouf the coirect fee:
Other Fee N Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park S}all O to 200 Amps 0 to 100 Amps
Slreet ltg./Tmffic Sig. Abave 200—Amps Above 100_Amps
Transformer/Generator INSPECTON'S USE ONLY T�TA�I�`T
Sign/OudineUg.Xfmr. ,�eQ. yiiZ� �� •J� J«
AlarmlRemote Control % 'n °s°`v" 6"'�^}�
$wimming Pool I here cerf �hot I ire red the elecrckal � iallotio� dexribed here�n an ihe doies nared
Irrigation 8 aooql+l� -^�" �0��' J��_
� Invesfigative Fee '— -- �� - � � '
THIS INSTALLATION MAY BE ORDERED DI5CONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE oNLY ihis requasi voidJ,B'momhs hom validotion do�e prnred in �his box.
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PLEASE PRINT OR TYPE
Reques� � Roughrn inapecnon reqoiradE Yes ❑ No Inspec�ion OMer Thon Roughan: ❑ Ready Now Will Coll
� ,� O� (1'ou most mll �he inspec�w wh n reody) Dme Reody
I, ❑ licensed canha<ror �owner hereby request inspection of the above eledrical work at.
Job Address �SheM, Bo or Rwie No.� Ciy �� Zip C�od.e.�I
�568 rNOc�.�c�� �Dc-t .5,7Z--�
Secfian No, iownship Name or No. Range N Fire No. Cou y
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STAiE BOApD CAPY - SEE�pUCI1pN�pN BACK OF YELLOW COPY