P - 81103� REQUEST FOR ELECTRICAL INSPECTION
4f ��� 513 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service M
"X" above ihe work covered by ihis request. Enter remarks in this space and on the back of the whi�e copy only.
Calculate Inspection Fee - This Inspection Request will not be accepied wifhoui 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 Am s Above 100 Amps
Transformer/Generafor INSPECTOR•s usE oN�v TOT L �
Sign/Oudine Ltg. Xfmr. �,
Alarm/Remote Conhol
Swimming Pool R .-fk�oo
1 hereb cefi that I ins the electrical installation described herein on the dates stated
Irrigation Boom Ro�9M� par�
Special Inspe ' r� %- �`-"
Finol
Investigative Fee �3 O ' �
THIS INSTALLATION NfAY BE ORDERED DISCO ED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This roquest void 18 monlhs irom validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Requesi Date Rou h-in ins on r uired$ ❑ Yes
g pecti eq ❑ No Inspeclion Olher Than RoughJn: ❑ Ready Now ill Call
�`/ou must call the inspecfor when ready) pate Ready:
i,�licensed conhactor ❑ owner hereby request inspection of the above elechical work at:
lob Address (Sheef, Box, or Roufe No.) City Zip Code
� ��'� �)
Section No. Township Name or No. Ranae No. Fire o. County
Occupant
�
Power Sui
�Confmctor or
or
Phone No.
Conkaclor License No.
- SE TAU ON BACK OP YELLOW COPY
No.