P - 84687c REGIUEST FOR ELECTRICAL INSPECTION -
4 Ci O- 6 01 Minnesota State Board of Electncity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 -
` Phone(612)642-0800
Home Duplex Apt. Bldg. Ofher: New Addn
Commercial Indushial Farm emod Re ir
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 Request will not be accepted v4ithou/ the correct fee:
Other Fee # Service Entranc 'ze Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 t ps 0 to 100 Am
Street Ltg./Traffic Sig. Abo e 00 Amps Above 100 Amps
Transformer/Generator INSPECTOR•s use p�1�Y �_? w� TOTAL .�
Sign/Out�ine Ltg. Xfmr. G��l'Q% '�6`!�'t '
Alarm/Remote Confrol � �. � ",$—^
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Swimming Pool ) ��
I hereb certi fhat I ins ted the elechical installation described herein on th�a^ st
Irrigation Boom eou M�
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHI�1 18 MONTHS.
OfFlCE USE ONLY This request void 18 months from validation dafe ' box.
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Requ=sf Dafe _ � Rou h-in ins on re uired? ❑ Yes
g pecti q ❑ No Inspecfion Olher Than RougMn: ❑ Ready Now ill Call
(You must call the inspector when ready) Dafe Ready:
I,�icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.� . Ciy _ Zip Code
I Power
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Phone No.
oI1�n1Y1 �L.Lm��RICIJI�RV�CES Conhactor License No. Master Lic. No. (Planf
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STATE BOARD COPY - SEE 1 UCTIONS ON BACK OF YELLOW COPV