P - 84662RE�UEST FOR ELECTRICAL INSPECTION �-•�
/i /� �� Q C, �] Minnesota State Board of Electricity
�t `T �+ ..! 1 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indushial Farm Remod Re ir
Air Cond. Hfg. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ►he work covered by this r ues►. Enter remarks in this space and o the ba of the hite copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted withou► 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./Traific Sig. Above 200 Amps Above 100 A�
Transformer/Generator INSPECTOR�S USE ONLY T�Ti,
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimmin4 Pool
Fee
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the elechical insfallafion described herein on fhe dafes stated
Dafe
� Investigative Fee T � _ �-�"�� - I��- J�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE U8E ONLY This request void 16 monfhs from validation date printed in this box.
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PLEASE PRINT OR TYPE
R uesf Dafe Rough-in inspecfion required? es o Ins tion Olher Than Rou Mn: � eady Now
�� P� g ❑ Will Call
�You musf call the inspector wh rea y Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob ddress �Sheef, Box, or Route No.� Cih, Z�P C�
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Section . wnship Name or No. Rn��a c�.e r.i,, r...._...
co�h«�o�
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I Mailing
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Phone No.
^Y� �(,L Conhacfor License No.
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or Owner PerForming nstallaKon� �
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Owner Performing Install �
� �5215
STATE BOARD COPY - SEE INSTRUC710NS ON BACK OF
r Lic. No. (Planr Elect. Only)
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