P - 84167� REQUEST FOR ELECTRICAL INSPECTION
����� � 4� 3 �°` Minnesota State Board of Electricity
, 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg. Oiher: New
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Commercwl Industrial Farm Remod Re a
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enier remarks in this space and on the ack of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted 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 �jS"
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�S USE ONLY TO
Sign/Outline Ltg. Xfmr. ,�1�— ��G —
Alarm/Remote Control ��
Swimming Pool
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I hereb certi that I ins the electrical installation dexribed herein on the dates sfafed
Irri9ation Boom Rough�ln , pa
Special Inspecti ' � ��Z —
Final'
Investigative Fee ��'--�'
THIS INSTALLATION MAY BE ORDERED DISCO CTED IF NOT COMPLETED WITHIN 8 ONTHS.
OPFICE USE ONLY This request void 18 monfhs (rom validation dafe printed in fhis box.
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* � 5 0 8 4 0 3 3* PLEASE PRINT OR TYPE
Requesf Date Rough-in inspecfion required? Yes
j ❑ No Inspection 01her Than Rough-In: ❑ Ready Now ill Call
r a'`� -� �� (You must call the inspecfor when readyJ Dote Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
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Section No. Township Name or No. Range No. Fire No. ounN
Occupant
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Power Supplier
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S;gnature
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or Owner Performing Installation)
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c�or or er Pe min Installation)
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STATE BOARD CO SEE
Phone
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Conhactor License No.
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Master Lic. No. I ant Elect.
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Phone No.
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