P - 80683RE(�UEST FOR ELECTRICAL INSPECTION
��C�� n(� � Minnesota State Board of Electricity �
.��, la �7 � 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 '' '
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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. $ervice
"X" above the work covered by ►his request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspecfion Fee - This Inspection Request will not be accepied without the correct fee:
Other Fee # Serv'ce Entrance ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 0 Amps 0 to 100 Amps
Sfreet Ltg./TraFfic Sig. Above 200 Amps Above 100 Amps �
Transformer/Generator INSPECTOR'S USE ONLY T
Sign/Outline Ltg. Xfmr. � r X�G
Alarm/Remote Control ��
Swimming Pool
. I hereb certi thaf I ins fed fhe elechical installafion described herein on the dafes sfafed
Irriqation Boom R����I,-lo i^'� s Data. __ �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MOIVTHS.
OFFICE USE ONLY This requesf void 18 monihs from validafior dafe printed in ffiis box.
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PLEASE PRINT OR TYPE
R uest Dafe Rough-in inspecfion required? es ❑ No Inspection Other Than Rough-In: ❑ Ready Now ill Coll
�— Z, �You must call the inspector when ready) Date Ready:
I, icensed confractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheef, Box, or Roufe No.� City Zip Code
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Seclion No. Townshio Name or No. Ranqe No. Fire No. Couny � �
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Power Sup er Addre
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EI�I Conhacror (Company Name� �
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Mailin Address (Contracfor or Owner Performing Insfallation ��
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Aufhorized Sign (C9pir�e O Perfor g Insfa ation) A
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B-OOOOIhI l 8/96 STATE BOARD COP EE INS
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Phone No.
5 , � S� I � 3z.
License No.
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1� 42
;TI6NS ON BACK OF YELLOW COPY
Lic. No. �Plant Elec
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