P - 80674�l' �� / T RE(�UEST FOR ELECTRICAL INSPECTION -_���<..
�� 1���� � Minnesota State Board of Electricity
� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
�j� Phone (612) 642-0800 `
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Home Duplex Apt. Bldg. Other: New ddn
Commercial ndustrial Farm Remod Re air
Air C 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 ihe white copy only.
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Calculate Inspec►ion Fee - This Inspection Request will not be accepled without ihe correc► fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
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 INSPECroR'S USE ONLY TOT L
Sign/Outline Lfg. Xfmr.
Alarm/Remote Control �� .S�
Swimming Poo!
I hereb certi fhat I ins fed the eleclrical installafion dexribed herein on the dafes stated
Irrigation Boom RougMln Dare
Special Inspec
�7 �Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECT�F NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request wid 18 months kom validafion date prinfed in ihis box.
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* 0 7 5 1 3 8 5 6* ��7�
LEASE PRINT OR TYPE
Requesf Date Rough-in inspecfion required$ ❑ Yes No InspeMion O�er Than Rouglrin: Ready Now ❑ Will Call .
�� �You must call the inspecfor when ready) Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the obove electrical work at:
Job Address Strcet, Box, or Route No.) Ci � Zip
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or No. I Ranae No. I Fire No.
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Contjyxtor (Company Nome� � Conhactor License No. Masfer Lic. No.
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�ddre9 �Contracror or Owr�r Performin�-Installation) ^ � n� � �
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BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
No.