P - 81530�
75�-a30
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Home Duplex
REQUEST 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 Industrial Farm Remod Re
Air Con Htg. Equip. Water Htr. Load Mgmt. Ofher:
Dryer Range Elec. Heat Temp. $ervice
"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 withou► the correc► fee:
Other Fee # Service Entranc ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 0 Amps � 0 to 100 Amps Q•Q
Street Ltg./Traffic Sig. Abov 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. �5.�
Alarm/Remote Conhol
$wimming Pool
I hereb certi fhaf I ins fed the elechical installafion dexribed herein on fhe dafes stated
Irrigation Boo RougMn
$pecial Insp
Final
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCO ED IF NOT COMPLETED
18 MONTHS�
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OFFlCE USE ONLY This request void 18 months from validofion daTe prinfed in this box.
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PLEASE PRINT OR TYPE
Request _� Rougl�in inspecfion required2 ❑ Yes No Inspecfion Other Than RougMn: ❑ Ready No ill Call
�You musf call the inspecfor when ready) Dafe Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job�s f$heet, Box, or Roufe No.) City Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Couny
Power $upplier ,,,) " I Address
ec ical Contracfor (Company Name) �
Mailing Address (Conhactor or Owner Performing Instp�afion) _
Contractor License
Phone N� — ��
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- i
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
Lic. No. (Planf Elect. Only)