P - 83036REQUEST FOR ELECTRICAL INSPECTION ��
6 7�� � 1� � Minnesota State Board of Electricity ��
• 1821 University Ave., Rm. S-128, St. Paul, MN 55104 -
, ` Phone (612) 642-0800 "�'
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Home Duplex
Commercial Industrial
Air Co�S Nta. Eau
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work cov
Farm
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
this request. Enter remarks in this space and on the back of the
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance 5ize 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 TOTALC�
Sign/Outline Ltg. Xfmr. � �J ��
Alarm/Remote Conhol
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS_
OFFICE USE ONLY This request void 16 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
�°� ^(�^, Rough-in inspecfion required? ❑ Yes No Inspecfion Ofher Than RougMn:
�p ��J� �8 �You must call the inspector when ready) Date Ready:
licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Iress �Sheet, Bo or Route No.) City
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No. Township Name or No. Range No. Fire No. Co_
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Conhacfor (Compan Nam�
BlA1NE HTGi. A;G� ELECT., INC.
Ready Now ill Call
Phone No.
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STATE BOARD COPY - SEE {NSTRtlCT10NS Oti BACK OF YELLOW COPY