P - 84622RE(�UEST FOR ELECTRICAL INSPECTION
4��= 6 9 5 Minnesota State Board of Electricity
. 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
` Phone (612) 642-0800
Home Duplex Apt. Bidg. Other: New Addn
Commercial Indusfrial Farm Remod Re ir
Air Cond. Htg. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" abov the work covered by this request Enter remark in this space and on the back of the white co only.
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Calculate Inspection Fee - This Inspection Requesi will not be accepted withou► the correct fee:
Other Fee # Service Entra Size Fee # Circuits/Feeders Fee
Mobile Home Park $tall 0 to 00 Am s 0 to 100 Amps
Street Ltg./Traffic Sig. Abo e 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T T�
�ign/Oudine Lig. Xfmr.
Alarm/Remote Confrol
Swimming Pool
I here certi that I ins the eleclrical installofion described herein on the dates stated
Irrigation Boom RougMn pa A�f
Soecial InsnPrfi G' M!"' ��2�`/ /
Investigative Fee�— "' � � � ''""�/�%��G�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
E USE ONLY This request void 18 monlhs (rom validation dafe printed in this box.
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* � 4 3 ]� 6 9 5 j� �IC PLEASE PRINT OR TYPE ��dc�-S�
Request Date Rougffin inspecfion required? Yes 0 No Inspeclion Other Tiian RougMn: � Ready Now ❑ Will Call
`� �' (You musf call the inspecfor when r dy� Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job A ress (Sheef, Box, or Route� N�p.) City � :.� Zip Code
n No. Township Name o�r�No. � Range No. � rvel������ - .
Addreu
� on o ny rvam ,� Conhactor License No. Masfer Lic.
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4ddress (Conh Owner Performing Installali �
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IE Signalure acto pvan p ming InsTallafion) /�J � Phone No.
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A�� �� STATE BOARD COPY E IN TRUCTIONS ON BACK OF YELLOW COPY
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