P - 82729REQUEST FOR ELECTRICAL INSPECTION
5 6 5- V J J � Minnesota State Board of Electricily
1821 Universiiy Ave., Rm. S-128, St. Paul, MN 55104
� Phone (612) 642-0800
Home Duplex Apt. Bld . Other: New Addn
Commerciai Indusfrial 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 requesL Enier remarks in this space and on the back of the white copy only.
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Calculate lnspection fee - This Inspection Request wiU not be accepied 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 S+g. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
me ug. xrmr.
mote Confrol
� Pool �
Boom i
that I inspected the elechical inslallation described herein on the dates
oa�e
THIS INSTALLATION MAY BE ORDERED DISCONI�ECTED IF NOT COMPLETED WlTHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validafion date printed in Ihis box.
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PLEASE PRINT OR 7'YPE
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e� g pection required8 ❑ Yes ❑ No Inspecfion O�er Than Ro�$Mr: O Reody Now � yy;l! Call
� L� � Z��(� �You must call the inspector v✓hen ready) pa� R��,: q��n
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I, �licensed conhactor ❑ owner hereby request inspection of the above electrical work at:
1ob Address �streer, Box, or Ra,1e No.) C�y
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SecTion No. Tovmship Name w No. Range No. Fire No. [ti�..n.
Occupont
Phone No.
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.al Con� r (� �ny Name) I --.-`
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� Address (Conhactor or Owner Performing InsfallaKon)
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zed SignaNre Conhacfor w ner PerForming Instoll�ion)
IiA-11 8/96 pT� gOARD COPY - SEE I
Conkocfor License
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Lic.
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ON BACK OF YELLOW COPY