P - 80987REQUEST FOR ELECTRICAL INSPECTION _
8 A����� � Minnesota State Board of Electricity
`f 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612j642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial ndustrial 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. Enier remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will nof be accepted without fhe correci 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 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TO L�Q
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Pool
I hereb certi thaf I ins fed the electrical instal�afion described herein on the dates stated -
Irrigation Bo i; RougMn Date
Specinllnsp io �
Investigative Fee F��I �� D���L ��f- C�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
. OFFICE USE ONLY This requesf void 18 months from validaiion date printed in this box.
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P EASE PRtNT OR TYPE
Requ sf Date Rough-in inspecfion required? ❑ Yes No Inspection Ofher Than Rough-In: Ready Now ❑ Will Call
�� I3 —� (You must call the inspecfor when ready� � Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreei, Box, or Roule No.� �� City Zip Code
� W �
Section No. Township Name or No. Range No. Fire No. Coun
Phone No.
�.,'11��n1v�1Z� `l f�l�_
•- � Confractor License No. � Master Lic. No.
or Vw er Pertormin Installafion)
�.L� � �� � �l -��� L �1r���:��,�_h�N S�
i�.orflwner Performina Installafion) f ' 1—�� Phone No. _
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STATE BOARD COPY - SEE INSTRUCTIO OF YELLOW COPY