P - 83255..
J�O�VIJV �
REQUEST FOR ELECTRICAL INSPECTION �:
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone(612)642-0800 " �
Duplex Apt. Bldg. Other: New
Commercial Industrial Form Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:/��Q� � Q�
Dryer Range Elec. Heat Temp. Service 4���
"X" above the work covered by this request. Enter remarks in this space and on the bac of the white copy gAly.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps -5� 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR's use ON�v TOTA ��Ri
Sign/Outline Ltg. Xfmr.
Alarm/Remote Conhol
thai I insoacted 1he electricol installofion described herein on the dates stafed
Boom
Investigative Fee �°- - rf _Z"�
THIS tNSTALLATiON MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months 6om validofion da�e printed in this box.
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PLEASE PRINT OR TYPE
Request Date,,.� �� w Rou frin ins fion r uired?
SC' �j/ g pec eq ❑ Yes o Inspection Ofher Than RougMn: ❑ Ready Now Will Call
V � �You must call the inspecfor when ready) Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address (S�� , pr Rqyte No.�� `� � ��� City �� le Z�P •��
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Section No. Township Name w No. Range No. Fire No. Cou
Occupanf �� / _ ��
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Power Suoolier
Signature
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� TATE ARD C - SEE tNSTRUCTIONS ON BACK OF YELLOW COPY
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