P - 81045- RE(�UEST FOR ELECTRICAL INSPECTION :�,
`�'U �° 15 2� 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 ►he work covered by this request. Enter remarks in this space and on the back of e w iie c�o 'yJ /only.
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Calculate Inspection Fee - This Inspection Reques► will not be accepted without the correct fee:
Other Fee # Service Entran Size Fee # Circuits/Feeders Fee
Mobile Home Park S�all 0 to 00 Amp 0 to 100 Amps �
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR•s usE oN�r ,, "
line Ltg. Xfmr. � Zg�}S�-�
mote Control �
a Pool
I hereb certi thaf I ins
Booma,,,,,,�.,
on Ihe
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFfiCE tlSE ONLY This request v�oid 18 monfhs from validation dafe prinied in fhis box.
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PLEASE PRINT OR TYPE
R��D/ Rough-in inspection required? ❑ Yes No Inspecfion Ofher Than Rough-In: eady Now 0 Will Call
�v (You must call the inspector when ready) Date Ready:
I, �icensed confractor ❑ owner hereby request inspection oF the above elecfrical work at:
Job Address (Skeet, Box, or Roule No.) � City � Zip���
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Section No. Township Name or o. Range No. Fire No. Counly � �
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O,c%�j n)f /� % % Phone No.
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ress �Contractor or Owner Performing Installc
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anafure IConhacMF or �rner Pe mina In
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Conhacror License No. Master Lic. No. (P
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY