P - 83242RE(�UEST FOR ELECTRICAL INSPECTION
6� Q�� Q� � Minnesota State Board of Electricity
J V 1821 University Ave., Rm. 5-128, St. Paul, MN 55104
�
' Phone (612) 642-0800 '' �
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Form Remod Re air
Air Htg. Equi . Water Htr. Load Mgmt. Other.
Dryer Range Elec. Fleat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the whiie copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Pee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to )00 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL _
ine Ltg. Xfmr.
mote Control
� Pool �
Boom i
that I
Dare
I THIS INSTALLATION MAY BE ORDERED DISCaRN�CTED IF NOT COMPLETED WITHIN 18 MONTHS.
—Y— ------_ __ _— -- --------------
- OFFICE USE ONLV This request void 18 monfhs from validafion dafe printed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rougffin inspection required$ ❑ Yes No Inspecfion Olher Than Rough-In: Ready Now ❑ Will Call
� � (You must cal! the inspector when reudy� pafe keady: ��Q ��ri>'
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I, (�Q licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreet, Box, or Route No.) � Ciiy Zip Code
9�y-68f��1 u e NE i�r��%
Section No. Township Name or No. Range No. Fire No. County
MO �
Occupant Phone No.
��c�•ct Gra►11 u S7/ -.�30 (p
Power Supplier Addreu
!s Ec.EcTi��
Address �Conhacror or Owner
Conhactor License
L�4-D / y
Lic. No. IPlanr Elect.
" 4./ Z,.�n rn n 5.�3 8'
o� Owner PerForming Insfallafion� • A n r O�� Phone No.
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STATE ARD Y- SEE INSTRUCTiONS ON BACK OF YELLOW COPY