P - 83511REQUEST FOR ELECTRICAL INSPECTION °'E
�715 - 3 4 5 0 Minnesota State Board of Electricity 3
s 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �. °�
Phone (612) 642-0800 '�� �
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this reques�. 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 withouf the correct fee:
Ofher Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�v TOTAL/�
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that 1 ins ted the electrical instaliation described herein on fhe dates stated
Irri9ation Boom RougMn Date
Special Inspectio �
Final D
Investigative Fee ` �'2-Q'��,7
THIS INSTALLATION MAY BE ORDERED DISCO ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Requ f D Rough-in inspec}ion required$ ❑ Yes � o Inspecfion Other Than Rough-In: eady No ❑ ill Call
(You must call If�e inspector when ready) Dafe Ready:
I, licensed contractor ❑ owner hereby request inspection of the above elechical work at:
Jo Apl�ress Sh4et, Box, oC� / � Cih, Zip Code �
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Secfion No. Township Name w No. Range No. Fire No. Covnly
Occupanf �
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Power Suooli
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Owner Performing lostallati
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ir or Owner Perfor n Insfallafion� Phone No.
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BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
Phone
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License No. Masfer
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