P - 80657r REGIUEST FOR ELECTRICAL INSPECTION
�i o�-� 5 6� Minnesota State Board of Electricity ;�
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 `'�'
Home Duplex Apt. Bldg. Other: r� New Addn
Commercial Industrial Farm v' h� Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this reques►. Enter r marks in iis space and on e back of the white copy only.
. /J �
. �
Calculate Inspection Fee - This Inspe
Other Fee
Mobile Home Park Stafl
Street Ltg./Traffic Sig.
Transformer/Generator
$ign/Outline Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Pool
Irrigation Boom
S ecial Ins e '
�n Request will not be accepted without the correct fee:
# Service Entrance Size Fee # l Circuits/Feeders Fee
0 to 200 Amps 0 to 100 Amps
Above 200 Am s Abbve 100 Amps
INSPECTOR'S USE ONIY � TOTAL� ��
I insoected the elecirical
a
ai
on the dWes stafed
P P Fiiwl oate
Investigative � ' 2—t�3
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months from validafion dafe printed in fhis box.
��Ill����if��fl��lfl����l���l��{��� •
NIIIIi�I a_�
* 0 8 D 1 6 5 6 0� ��
PLEASE PRINT OR TYPE
Requ t D e Rough-in inspeclion required? ❑ Yes Ins fion Olher Than Rou Mn: ead Now
P� g y ❑ Will Call
�You must call the inspector when ready) Date Ready:
I, ' ensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheef`Box, or Roufe No.) � �v Ci�y ^ ^ t Zip . e ��
7
;''� ;
Section o. Township Name or No. Range No. Fire No. Coun /' / �' F� C' i�
Dccu�'✓ `/ � 1.CNV � ^ Phone�lq ry� W�/ l
l 1CU
��
�c��'����
or vwner rerrormmg InsTallafion)
f � ;� Crh�Yl� t,�
BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
�i
i�
�