P - 83097REGIUEST FOR ELECTRICAL INSPECTION ��
6� 3 5 5 Minnesota State Board of Electricity
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.
Calculate Inspection Fee - This Inspection Request will nof be accepted without fhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 t 2 mps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�r TOTAL �
Sign/Oudine Ltg. Xfmr. —�►
Alarm/Remote Conhol
Swimming Pool � � ���''�
. _ I hereby certiiy fhat I inspecled the elechical installation described h n on th dates
Investigative Fee ���� ' � � �- �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPIETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rou h-in ins fion r uired2 1�Yes
�� ^ g pec eq f` ❑ No Inspection Other Than Rough-In: ❑ Ready Now Will Call
7� �You must call the inspecror when ready) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Addreu �Street, Box, or Route No.) Ciy Zip Code
g C�/a ��" �e
Section No. Townshio Name or No. Ranae o. Fire No_ G�nn� . _
� Occupant
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Eleclrical Conhatlor (Company Name)
1� �i�c
Mail�Add� Conhactor or Owner PerFomyrg In��n)
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Aufhori�ed $ignature (Cyqha or Owner PerForming Installa
A-1 1 8/96 STATE BOARD COPY - SEE
hacfor License No. Master lic. No.
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Phone No.
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�S ON BACK OF YELLOW GOPY