P - 84715�31-33�
Home Duplex
REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone(612)642-0800
Other: New Addn
Commercial Indushial Farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by lhis request. Enter remarks in this space and on the back of tF
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuit
Mobile Home Park Stall 0 to 200 Amps 0 to 100 A
$treet Ltg./Traffic $ig. Above 200 Am s Above l OQ
Transformer/Generator INSPECTOR'S USE ONLY
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
copy
Fee
I hereb certi that I ins ted the elechical insfallafion described herein on the dates stated
Irrigation B Ro�yMo pa�
Special Ins
Final pa
Investigative Fee �p— Z %- p'
THIS INSTALLATiON MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monihs from validation dafe prinfed in this box.
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* � 4 8 1 3 3 6 (� * PLEASE PRINT OR TYPE
Requesf te RougMin inspecfion required? ❑ Yes �"Ido Inspection Other Than RougMn: �Ready Now ❑ Will Call
�You musf call fhe inspector when ready) Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.) Ciy � Zip Code
Secfion No.
Occupant _
I Aufhorized
or No. � Range
�
;ror�Company Name
1
�Conhactor or Ow
iture (Conhactoi or C
_� � c
Phone No.
0
Masfer Lic. No. (Planf Eleci. Only)
me No.
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