P - 82615REGIUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity
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7��- 2 6 4� 1821 University Ave., Rm. S-128, St. Paul, MN 55104 ���
�` Phone (612) 642-0800 ����
Home Duplex Apt. Bldg. Other: New Addn
Remod Repair
Commercial Industrial Farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered �y rhis re uest. Enter r marks "n this space and on the back of the white copy
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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 Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA �r�
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool �
I hereb certi that I ins cted the electrical insfallation described herein on the dates staled
Irrigation Boom �� RougMn Date
Special Inspecti ��
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Investigative Fee
_ THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLV This request void 1 8 monihs from validafion dafe prinfed in fhis box.
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PLEASE PRINT OR TYPE
Request D te Rou h-in ins ecfion r uired?
� � I�� g p eq ❑ Yes No Inspection Ofher Than Rough-In: Ready Now � Will Call
(You must call the inspector when ready) Date Reody:
I, . licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Ad s Streyt,,,$q�C, or Route No.) Ciy Zip Code
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Section No. Township Name or No. Range No. Fire No. County
PaWe.
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(� Phone No.
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- _. Address
�Company Name)
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nfractor or Owner Performing
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VCoohac r or Owner PerForming Insfallation� � Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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License N�o.p, Master Lic. No. �Planf Elecf. Only)
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