P - 84671REGIUEST FOR ELECTRICAL INSPECTION �
i'� � b- 7 6 9 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �.
Phone (612) 642-0800 '
Home Duplex Apt. Bldg. Other: New Addn
ommercial Indushial Farm Remod Re ir
Air Cond. Htg. Equip. Water Hh. 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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Calculaie Inspection Fee This Inspection Request will not be ac�without the co ct fee.
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg./Tra�fic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOJ��iI
Sign/Oudine Ltg. Xfmr. � v
Alarm/Remote Conhol
Swimming Pool
I hereb certi thaf I ins ted the electrical ' stallation described herein on }fie dotes smfed
Irrigation Boom Rough-In • ate �
Speciallnspeeti � �- '"
. Final . �ore
Investigative Fee —
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation dafe prinfed in this box.
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Regyesf � Rough-in inspection required? ❑ Yes o Inspecfion Other Than RougMn: ❑ Ready Now �II Call
� (You must call the inspector when ready) � Date Ready:
I, " ensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job/�dfess (She�(, Box, or I;oute No.� City�_ , Zip Code
Seclion No. I Township Name or No. I Range No. I Fire No. I Coun /�
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Power
Eleckical Conhactor (Company Name�
or Owner Performing Installation)
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No. �Plant Elec1. Only)