P - 80329,fJ-89�-558 �
Home
Apt.
REQUEST FOR ELECTRICAL INSPECTION ��
Minnesota State Board of Electricity 1�
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 =
(651) 642-0800 www.electricity.state.mn.us `�'
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy
_�'�`�`�"'`-' � �'%l't-�-l"� ---�d/ � '�'�! l..-L� -
(�� �v (� < < � ��-v'1��(�h
Calculate Inspection Fee - This Inspection Request will noi be accepted wiihout ►he correc► fee:
Other Installations Fee # Service Enkance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
$wimming Pool
Irriqation Boom
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
that �
Repair
0 to 100 Amps
Above 100 Amps
TOTAL
ag �``�-
� � Investigative Fee j'" " � - � ��`"� "'L'''' �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
._ OFFICE USE ONLY This request void 18 months 6om validaHon date printed in this box.
��IU���������M�l� a.5-c�
� �
* D 8 9 2 5 5 8 8 * �r13
PLEASE PRINT OR TYPE
� Request Dafe Rou h-in ins ecfion r uired? ❑ Yes
9 P 89 ❑ No Inspection Other Than Rough-In: Ready Now ❑ Will Call
+ ��� You musf call fhe inspector when ready Dafe Ready:
1, �Iicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Rolule No.) Ciy f Zip Code
� ��s . �
Sec �on No. Tow�ship Name or o. Range No. Fire No. y
��� ° — — Phone No.
e
�� �
Power Supplier (, ` Address
��V V V
Elechical r�ract / Compony Nome Conhactor License No.
�G
Mailing Address (Contractor, Company or Owner Performing Installation) __ ,� ,
Signature ��ntractor, Company or
STATE BOARD COPY
I k�t) r�g—q,�3c� �
SEE INSTRl1CTIONS ON 6ACK OF VEILOW COPV