P - 79501REQUEST FOR ELECTRICAL INSPECTION
�� �� o��� � Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642- 00
Home Duplex Apt. Bldg. Otherj �� rn�—�'� New Addn
Commercial Industrial Farm � J� Remod Re air
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 only.
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Calculate Inspection Fee - This Inspection Requesi will not be accepied 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
Street Ltg.fTraffic Sig. Above 200 Amps Above lOQ Amps
Transformer/Generator INSPECTOR'S USE ONLY / TOTAL >
Sign/Outline Ltg. Xfmr. r`Lg/,1i� � �C �� �/ �
AlarmJRemote
Swimming Pool
Irriqation Boom
� Investigative Fee � �
THIS INSTALLATION MAY BE ORDERED
IIII II III I I I II {I II4 II {II {I III I I II I II III ��I I�II
* 0 8 0 2 3 2 9 3*
d the eleclrical installafion described herein on the da
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DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation dote printed in fhis box.
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PLEASE PRINT OR TYPE �— I� J v
Kequest uate Rough-in inspecfion required$ ❑ Yes o Inspection Ofher Than Rough-In: ❑ Ready Now 0'�Nill Call
� `'1 D (You musf call the inspecfor when ready) Dafe Ready:
I, ❑ licensed contractor 0 owner hereby request inspection of the above electrical work at:
lob Address (Sheet, Box, or Roufe N � Ci Zi Code
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Occupanl
Mailing Address �Conkador or
or No. � Range
or
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I Master Lic. No. fPlan
BOARD COPY - SEE INSTRUCiIONS ON BACK OF YELLOW COPY