P - 83201RE(1UEST FOR ELECTRICAL INSPECTION —�
5 L. J= 2 9 0 Minnesota State Board of Electricity
� 1821 University Ave., Rm. 5-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex A t. Bldg. Other: New Addn
Commercial Industrial Farm Remod ir
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heot Temp. Service
"X" above tl�e work covered 6y this request. Enter remarks in this space and on the back of�hite copy only.
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Cakulate Inspection Fee - This Inspection Request will not be accepted withouf the correct fee:
Other Fee # Service Entrence Size Fee # Circuits/Feede
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL���r
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi tlwt I'rns the eleclricol insmllation described herein on the dates s�alad
Irrigation Boom Ro�Mn Dare
Speciallnspecti 1 �
Fina) Da
Investigative F i -�
THIS INSTALLATION MAY BE ORDERED DISCONNECTEb IF NOT COMPLETED WITHIN 18 MONTHS.
_ O� t18E ONLY This requesf void 1 B months (rom validahon d��peinted in this box.
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� PLEASE PRINT OR TYPE '
Reque�le �� �- . -:
� Rou9h-in i�spedion required? ❑ Yes No Inspeclion Other Than Rough-In: Ready Now 0�II Call
� �� (You must call the inspecror when ready� pa� R� : "
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I, licensed confractor ❑ owner hereby request inspection of the above elecfrical work af:
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Sectio^ No. Township Name or o. �- �. . Range No. Fire No. Coun i
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Phone No.
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Power Supplier , � ��5 �
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Electrico Contracror (C pa me) Conhacfor License No. Masfer lic. No. �Plant Elecf. OnIJ�
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Mailing Address (Contractpr or Owner Performing InsAnllafion)
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Auf�ho ' i alu (Conkacfor or Owner Perfo ' Ilalion Phone No.
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STAT D COPY - SEE INSTRUCTIONS ON BACK OF YELL�W 11fPV