P - 84551REGIUEST FOR ELECTRICAL INSPECTION
`i�'tJ J- 6 6 4 � .Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-OS00
Home Duplex Apt. Bldg. Other: New Addn
C mmercial Indushiai Farm Remod Re ir
ir C tg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" ve 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 not be accepted without the correct fee:
Other 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 ONLY TOTAL
Sign/Oudine Lfg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi fhat I ins ed ihe elecfrical installafion dexribed herein on the dates sfated
Irrigafion Boom Rouyfi-In Date
Speciallnsp ��
Final p l �
Investigative Fee ` ' (
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLV This requesf void 18 monfhs from validafion dafe prinfed in this box.
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* � 4 6 9 6 6 4 7�Ic PLEASE PRINT OR TYPE
Reque Dafe Rough-in inspecfion required? ❑ Yes
❑ No Inspection Other Than Rough-In: dy Now ❑ Will Call
�You must call fhe inspecfor when ready� Date Ready:
I, icensed conhactor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or oute No.� City�/ I i Zi Code
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Section No. Township Name or No. Range No. Fire No. un � D��
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� � Conhaclor License No.
�ergna re ��.onrtacror or Vwner rertorrtlln I Ilafion� ( t I ph��
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A-1 1 8/96 gpppD COPY - SEE INSTRUCTIONS ON BACK OF YELLUW COPY