P - 83274REGIUEST FOR ELECTRICAL INSPECTION =
5/��� ���� Minnesota State Board of Electricity
, 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 Re ir
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the rk covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted wifhovt ihe correct 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 TOTALr/ _.
line Ltg. Xfmr.
mote Control
� Pool
Boom
Special Inspect o ` — o
Investigative Fee Find �_ . � �
THIS INSTALLATION MAY ORDEREO DIS(�NiECTED IF NOT COMPLETED HIN 18 ONTHS.
OFFlCE U5E ONL1/ Thia requeat void 18 months from validation date printed io this box.
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Request ^� Rough-in inspection requiredZ s No Inspection O�er Than RougMn: ❑ Ready Now �II Cap
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� (You must call the inspecfor readyJ Date Ready:
I, ❑ licensed contractor,p�Qwner hereby request inspection of the above elechical work at:
lob Address (Sireet, Box, or Rou1e No.) Ciiy Zip Code
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'on No. Township Name or No. Range No. Fire No. Couny
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Mailing Address �Contractor or Owner Performing Insiallation)
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.icense No. I
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11 96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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