P - 81041:�
?�5-825 �
REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 5510
Phone (612) 642-0800 �%� s
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Home Duplex Apt. Bldg. Other: '
Commerciol Industrial Farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the whil
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Calculate Ins ection Fee - This Inspec►ion Request will not be accepied without ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feed�
Mobile Home Park Stall 0 to 200 Amps to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100
Transformer/Generator INSPECTOR•s use on�r TC
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
I herebvi cerli(v that I insoected the elechical installafion described herein on the �
New
Remod
>y only.
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Fee
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� Investigative Fee -`�'+` � �U � /•�� J
i THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE Op�Y This requesl void 18 months 6om validation date printed in this box.
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P EASE PRINT OR TYPE
Request Date _ _ Rough-in inspeclion required$ ❑ Yes No Inspeclion O�er Than RougMn: ❑ Ready Now Will Call
��You must call the inspecfor when ready Date Ready:
I, licensed contractor ❑ owner hereby request inspection of ifie above elechical work at:
Job Address (Sheef, Box, or Roufe No.) Ciry Zip Code
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Secfion No. I Township Name or No. I Range No.
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ower Supplier Addreu
EI I Conhact ompan me) ,
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Mai ing Address (Confmdor or Owner Performing Installation)
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Auf ized S�ature �Conhq�pr or C�w9er� rming�tallaKon)
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BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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