P - 81787REQUEST FOR ELECTRICAL INSPECTION
Q(� � m��� � Minnesota State Board of Electricity
v�� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
'" Phone (612) 642-0800 ���
ome Duplex Apt. Bldg. Other. New Addn
Commercial Industrial Farm Remod e air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculaie Inspection Fee - This Inspection Request will not be accepted without the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 200 Amps 0 to 100 Amps
Street Ltg./Troffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltq. Xfmr. ��, �
Swimming i�'�iuQ
I hereb certi thot I ins ted the elechical installafion described herein on the dales sta�ed
Irrigation Boom RougMn pa�
Special Inspection
Final /
Investigative Fee �O ^ 2�10 ��
THIS INSTALLATION MAY BE ORDERED DiSCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requosf void 18 months kom validation dote prinfed in this box.
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PLEASE PRINT OR TYPE
Request Dale Rough-in inspecfion required2 ❑ Yes Inspecfion Other Than Rough-In: ❑ Ready Now ❑ Will Call
L-f' �o�.�-� �� (You must call The inspecfor when ready) � . Dafe Reody:
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I, ❑ licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Rouie No.) City Zip Code
i sr- �V � � � SSZI �
Secfion No. iownship Name or N Range No. Fire No. C y
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Occupant
Power Sui
Phone No.
C4ia��yl-o��r
D�.S /C.�I �-�'`Z'� �< v.
Conhacror License No. Masfer Lic. No. �Planf 1
Mailing Address �Cq,Mraefor or Owner Performirg InstallaKon� .
w�r Performing Insfallafion) 1 Phone No. p yI—O"1�S I
A /� � � 7
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STATE BOARD OPY - SEE INSTRUCTIONS ON BACK OF YELIOW COPY