P - 80720'� REQUEST FOR ELECTRICAL INSPECTION - �
C�,,,� C� 3�� � Minnesota State Board of Electricity
`� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New
Commercial Industrial Farm Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" ove the w rk cQvered by ►his request Enter remarks in th space and on the back of the whiie copy only.
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Calculate Inspeciion Fee - This Inspe
Other Fee
Mobile Home Park Sia11
Sheet Ltg./TraFfic Sig.
Transformer/Generator
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool
Irriqation Boom t n
m Request will not be accepied wi�hout the correct fee:
# Service Entrance Size Fee # Circuits/Feeders
0 ro 00 Amps 0 to 100 Amps
Above 200 Am s Above 100 Amps
INSPECTOR'S USE ONLY TOTAL
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I herebvi cerfiH thaf I insoecled fhe electrical insfallafion described herein on 1he dales sAO�ed
Fce
S�
� Investigotive Fee 5 '
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1_ _ M ..
- OFFlCE USE ONLY This requesf void 18 monfhs 6om validafion dafe prinfed in this box.
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* � 5 7 5 3 2 2 3 �K PLEASE PRINT OR TYPE
Requesf Da Rough-in inspection required? ❑ Yes {nspection 01her Than RougMn: Ready Now 0�II CaN
�j —�. g� �� �You must wll the inspecfor when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection oF the above electrical work at:
1ob dress (Sheet, Box, a Roule fJo.� Ci / Zip Code
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Secfion No. Township Name or No. Range No. Fire No. County � �
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pa� f Phone No. - � / �
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Power Suonlier Address
or ��.ompa�ry�ame�� � ��
� - � c� -- LLLC
�onhacror or Owner Performing InstaAation)
O�/�l„b l, f ��n �"� �
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Master Lic. No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON �ACK OF YELIOW COPY