P - 80265, REQUEST FOR ELECTRICAL INSPECTION
7��°�� 6 5� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New
Commercial Industrial Farm Remoc
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" obove the worK covered by this request. Enter re arks in this space and on the back of fhe white copy
Calculate Inspection Fee - This Inspection Requesf will nof be accepted without fhe correct fee:
Other Fee # Serv' rance F # Circuits/Feeders
Mobilti ome Park Stall 0 0 200 mps 0 to 100 Amps
Street Ltg./Traffic Sig. A 00 Amps Above 100 Amps
Transformer/Generator INSPECTOR�s use ow�v TOTAL
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control �/' �m �
Swimming Pool .��� �
I hereb certi that I ins the eleclrical installation de:cribed herein on the dates stated
Irrigafion Boom Rou M p��e
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Fee
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Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request wid 18 months from validafion date prinfed in this box.
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PLEASE PRINT OR TYPE
Request Rou h-in ins on r uired$ ❑ Yes
g pecti eq ' ❑ No Inspection O�her Than RougMn: ❑ Ready Now � Will Call
�'�$ �OQ (You must call the inspeclor when ready) Da�e Ready:
I, � licensed conhactor ❑ owner hereby request inspection of the above elechical work at:
Job Address (Streef, Box, or Route No.) City Zip Code
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or No. � I Ran9�� I Fire No.
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Conhacfor (Company Name)
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STATE BOARD COPY - SEE
Phone No.
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N BACICOF.YELLOW COPY