P - 84639REGIUEST FOR ELECTRICAL INSPECTION -_ �.
�. � y_ 2 3 9 Minnesota State Board of Electricity
%� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg. Ofher: New Addn
Commercial Indushial Farm Remod Re air
Air Cond.� Htg. Equip. Water Hfr. Load Mgmt. Other:
Dryer Ronge Elec. Heat Temp. Service
"X" above the work covered b this requesi. Enter emarks 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 accepted without fhe correct fee:
Other Fee # Service Entrance Size Fee #. Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps � 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL i��'(U
$ign/Oudine Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
I hereb certi If�af I ins the electrical installaKon dexribed herein on the dates sfoted
Irrigation Boom RougMn p�
Special Inspecfion
Final
Imestigative Fee _P
THIS INSTALLA RDERED DISCONNECTED IF NOT COMPLETED WITHIN 8 MONTHS.
OFFlCE USE ONLY This requesf void 18 months 6om validafion date prinfed in this box.
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Requesf Dafe Rou fFin ins tion r uvedt ❑ Yes
9 P� eq � ❑ No Inspecfion O�er Than Rough-In: dy Now � Will Call
� I�"�� (You must call the inspector when reody) pafe Ready:
I, �.I�censed conhactor ❑ owner hereby request inspection of the above elecfrical work at:
lob Address (Sheet, Box,_o{ Roy No.� C�� Z�P C�
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No. Township Name or No. � Range No. Fire Nol
EI 'cal Confracfo� �Company ame)
Mailin Address Conka or or Owner
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Aulhorized i onh or O�
Conhactw License
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