P - 82590: 1 �. ..
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: ,.i�lf
Commercial Industrial Farm
Remod
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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 r,ot be accepted wiihout the correct fee:
Other Fee # Service Entrance S" e Fee Circuits/Feeders Fee
Mobile Home Park Stall to 00 Amps ' 3 0 to 100 Amps -
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL ,�'Q
$ign/Outline Ltg. Xfmr. ��
Alarm/Remote Control c�
Swimming Pool o�
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I hereb certi fhaf I ins ecfed fhe elecfrical insfal }ion described herein on the dateYstate�
Irrigation Boom Rough-In D -
Special Inspection �
Investigative Fee Final �-� � ���
_THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 ONTHS.
OFFICE USE ONLY This requesf void 18 months from validafion date printed in this box.
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�F�,�.S�F�INT OR TYPE
Requesf Dat Rou h-in ins ection r uired? Yes
9 P eq ❑ No Inspection Other Than Rough-In: ❑ Ready Now ill Call
'�dQ (You musf call the inspector en ready) Date Ready:
I, ❑ licensed contractor owner hereby request inspection of ihe above electrical work at:
lob Address �Sfreet, Box, or Route No.� City � Zip Code
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Section No. Township Name or No. Range No. Fire No. CounN
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Power Suppli Address
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�ess ��ontracror ner Pert ming Installation
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Owner
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Phone No.
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License No. � Master Lic.
STATE BQARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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