P - 83049REQUEST FOR ELECTRICAL INSPECTION
p�.Ce `� 6 3 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: New
ommercial Industrial Farm Remod '
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other. S� ��Q�
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by is request. Enter remorks in t is space and on the back of the white copy c
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Calculate Inspection Fee - This Inspection Request will not be accepted withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Trpnsformer/Gene�ator INSPECTOR'S USE ONLY 7�0�
QC1
Sign/Outline Ltg. Xfmr. •X�� e
Alarm/Remote Conhol �
Swimming Pool
I herebvi certifv that I inspected the elechicol installation described herein on the dafes staPed
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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 void 18 from validation date prin�ed in this box.
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PLEASE PRINT OR TYPE
Request Date Rou ftin ins ection re vired? es
g p q ❑ No inspection Ofher Thon RougMn: ❑ Ready Now ill Call
.� ��� �You must call fhe inspector when ready) Dafe Ready: �
I, icensed contractor ❑ owner hereby request inspection of the above elechical work ah
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or No. - � Range No. � Fire No.
Phone No.
Conhactor License No. Master lic. No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY