P - 80342�-' REQUEST FOR ELECTRICAL INSPECTION °1e
� 3 2- 3 4 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 Addn
Commercial Industrial farm Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter re orks in this ace and on the back of the white�
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Calculate Ins�ction Fee - This Inspection Request will not be accepfed wiihouf ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sireet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps �
TransFormerjGenerator INSPECTOR'S USE ONLY �t1�, O L
Sign/Outline Ltg. Xfmr. d� �
Alarm/Remote Confrol �� ��
Swimming Pool -
I hereb certi thaf I ins the elechical installafion described herein on the dafes stafed
Irrigation Boom RougMn Date
Soecial Ins�ecti� f7 .�r � _
Fee
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�THIS INSTALLATION MAY BE ORDERED DlSCONNECTED lF NOT COMPLETED WITHI�l."1$�A�NTHS,_:
OFFICE USE ONLY This request wid 18 months kom validafion date rinted in this box.
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PLEASE PRINT OR TYPE
R est Date Rough-in inspection required2 ❑ Yes o Inspection Other Than RougMn: ❑ Ready Now � Will Call
Si ` �You must call the inspecror when ready) Date Ready:
I, �licensed conhactor ❑ owner hereby request inspection of the above elecfrical work at:
1ob Address �Sfreef, Box, or Route No.� Cily Zip Code
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secnon No.
Occupant
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Nome rn No.
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No. Fire No. Coun j
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Phone No. ��
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Conhador License No. Masfer Lic. No. �Pla
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Signature �Conha r or er Performing Insf�fation) Phone No
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�� 8� b STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW CO �,J'
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