P - 84141RE(IUEST FOR ELECTRICAL INSPECTION =-
5�U - 2 7 5� Minnesota State Board of Electriciry _
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 �"��
New
Commercial Industrial Farm """""
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter r arks in this space and on the back of the white copy
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Calculafe Inspection Fee - This InspE
Other Fee
Mobile Home Park Stall
Sfreet Ltg./Traffic Sig.
Tra nsformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irriqation Boom
�n Request will not be accepted without the correct fee:
# Service Entrance Size Fee # Circuits/Feeders Fee
0 to 200 Amps 0 to 100 Amps
Above 200 Am s Above 100 Amps
INSPECTOR'S USE ONLY TOTAL/�x
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I hereb certi that I ins the eleckical insfallafion described herein on the dafes sSnfed
., � , Date
� Investigative Fee � � \ �' F' ' �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.^
_ _ _ __
' OFFICE USE ONLY This requesi void 18 monfhs from validafion date prinfed in this box.
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7k Q 5� O 2'� 5 �* PLEASE PRINT OR TYPE =� S� �/
Request Dote,� �.y Rough-in inspection required? ❑ Yes No Inspection 01her Than Roughan: Ready Now ❑ Will Call
�� "'� �a � (You must call the inspector when ready� Date Ready:
I, �censed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Street, Box, or Ro ��Noy. Ciy Zip Code
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Section No. Township Name or No. Range No. Fire No. County :
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Occupanf
Power
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or Owner Per
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Phone No.
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Confr r Licen No.�� Master Lic. No. �Planf
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COPY
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