P - 832825.3�-529 ��
Home Duplex
Commercial lndustri
Air Cond. Hta. Ec
REQUEST FOR ELECTRICAL
Minnesota State Board of Electric'
1821 University Ave., Rm. S- , St
Phone (612) 642-0800 O `
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Apt. Bldg. Other. � �� .
Farm .7l ✓
Water Htr. Load Mgmt. er:
Elec. Heat Temp. Service
request. En►er remarks in this space and on the 6
�ION -
55104
New Addn
Remod Repair
copy
Calculate Inspection Fee - This Inspection Request will not be accepted without fhe correct fee:
Other Fee Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 200 Am s` ' � to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECrOR'S USE ONLY TOTAL„�, �
Sign/Oudine Ltg. Xfmr. ol
Alarm/Remote Control
Swimming Pool
I here cerTi that I ins the eleclriml installation describad herein on the da�es stoPed
Irrigation B RougMn Dare
Speciallns f
Investigative Fee F� ' C� —
THIS 1NSTALLATION MAY BE ORDERED D IF NOT COMPLETED WITHIN 18 MONTHS.
OFRCE lllE ONLY This roqwaf void 18 months from validafion date prin�ed in this box.
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Request Dafe Rough-in inspection required8 es Inspeclion Olher Thon RougMn: ❑ Ready Now ill Call
1� � g� (You must call the inspector whe eady) Dafe Ready:
I, ❑ licensed contractor � owner hereby request inspection of the above electrical work at:
.bb Address (Sheef, Box, w Roule No.) Ciy�' n Zip Code
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Seclion No. Township Name w�Jo Range No. Fire No. ny
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� o«opaor � Pho� No.
✓ ,,c�- L�►�,d11 - 01
Power Supplier Address
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Elecfricnl Confractor �Company Name) Contracror License No. Master lic. No. �Manf Elecl. Onl�
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Mailing Address �Conk r or Owner PerForming Insfallafion)
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Aufhorized Si ( acfor or er e rming In ta o � � Phone No.
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E��� STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY