P - 83942REQUEST FOR ELECTRICAL INSPECTION -_
� 5'� � 2/� 3 q Minnesota State Board of Electricity
�t 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
ome Duplex Apt. Bldg. Other: New
Commercial Indushial Farm Remod
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 ihe whiie copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without 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 Ar
Transformer/Generafor INSPEC70R'S USE ONLY TOT�
Sign/Outline Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Pool
I hereb certi that 1 ins fed fhe electrical insfallafion described herein on the dat�
Irrigation Boo� � _ RouqMn Dare
Fee
" Final � :� f� I D�� r) r ����(
Investigative Fee � ! �' /
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 months 6om validation date printed in this box.
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* � 5 5 3 2 4 3 7�IC PLEASE PRINT OR TYPE �5,�
Reque f fe (� Rough-in inspection required? ❑ Yes o Ins on Other Than Rou h-In:
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(You musf call fhe inspector when ready) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
lob Address (Sheef, , or R ute No.) City � Zip
i �: I�e • ` C
Seclion No. Towns ip Name or No. Range No. Fire No. Coun
Occupapl' � ��
;�;�
Power $uoolier
Name�
G. A/C ELECT., l;
PerFormiop
�
� 1`� '
Phone
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License�j o. Master Lic. No. (Plant Elect. Only)
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