P - 83491� 6.4�r-574
REtIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-OS00
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ome Duplex Apt. Bldg. Other: New ddn
ommercial Indusfrial Farm Remod Re air
Air Con Htg. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above tJ�,g w� cover� r, �si. E�ter_remarks � this space and on the back of the white copy only.
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Calculate Ins ection Fee - This Ins ection Re uest wi" 11 not be acce ted without fhe correct fee:
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Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic $ig. Above 200 Am s Above 1 UO Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT L � i�\
Sign/Outline Ltg. Xfmr. "J v
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins ted the elechical installafion described herein on the dates stoted
Irri9ation Boom RougMln �o�
Speciallnsp °
Final -
Investigative Fee -�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. '
OFFICE USE ONLY This request void 18 monfhs from validation dafe printed in this box.
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PLEASE PRINT OR TYPE
R uest Da'fe `^ Rou h-in ins ecfion re uired?
Y 9 p q ❑ Yes No Inspecfion Other Than Rough-In: Ready Now � Will Call
�You musf call the inspecfor when ready� DWe Ready:
I, licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
lob Addreu �Skeef, Box, or Roufe No.) Zip Code
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Section No. Township Name or
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Power Supplier
Elec rical Conhactor (Company Nc
Mailing Address onfrador or Ov
Range No. � Fire
IPhone No.
No. � Master Lic. No. (Planf Eleci. Only)
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY