P - 83892REQUEST FOR ELECTRICAL INSPECTION
5�. �� 115 Minnesota State Board of Electriciry
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 Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Requesi will not be acc<
Other Fee # Service Entrance Size
Mobile Home Park Stall 0 to 200 Amps
Street Ltg./Traffic Sig. Above 200 Am
TranSformer�Cienerator INSPECTOR'S USE ONLY
$ign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
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pted without the correct fee:
Fee # Circuits/Feeders Fee
0 to 100 Amps
Above 100 Amps
TOTAL y�
% � :�`
I hereb certi that I ins ted the elecfrical insfallation described herein on the dafes stated
Irri9ation Boom Rough-In Dare
Specia� InspectiaFi) � i+f , .
- � : Final .�-" �.> �°
Imestigative fee +- � _ oarQ� 7 J �
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinfed in fhis box.
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PLEASE PRINT OR TYPE
Request Dafe Rou h-in ins tion re uired?
, f- y� �� 9 P� q ❑ Yes No Inspecfion Ofher Than Rough-In: ❑ Ready Now ' ill Call
V�You must call ihe inspecfor when ready) Dafe Ready:
I, [�Jicensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address �Streef, Box, or Route No City Zip Code
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Secfion No. Township Name or No. Ranae Nn F��P N� Coun
Power
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il Conhacfor �Company Name) -�
B��NE �G• A/C ELECT.
Add�ess ���o��n�
A MfV 55?��
ed S ature (C ha r r ner Perforr�ng
EB-00001 A-
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Phone No.
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License I
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C- i. r,. �f ,.
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Lic. No. (Plant Elect. Only)
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