P - 81555� REGIUEST FOR ELECTRICAL iNSPECTION �
4J ��- 216 � 8121 Uni eSs ty A ear Rm. S-128, ISt. Paul, MN 55104 `�:
Phone (612) 642-0800 `'�'
Home Duplex Apt. Bldg. Other: New Addn
Commerciai 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 fhis request. Enter remarks in this space and on the back of the white copy only.
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Calcu ate Inspection Fee - This Inspection Request will noi be accepted without ihe correct ee:
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 T L
Sign/Outline Lfg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that 1 ins fed fhe eleclrical installaKon described herein on the dates stoled
Irriqation Boom - R,,,,,,ti_i„ o�
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rou h-in ins ion r uired?
g pecl' eq ❑ Yes No Inspecfion Other Than RougMn: ❑ Ready No Will Coll
/ O� (You musf call fhe inspecfor when ready) Date Ready: -
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, Roufe� No.) City Zip Code
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$ection No. Township Name or No. Range No. Fire No. Counly �
Occupanf
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Conhacror�Company Nome)
or
or
Phone No.
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Master Lic. No. (Plant Elecl. Only)
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STATE BOARD COPY - SEE 1NSTRUCTIONS ON BACK OF YELLOW COPY
No.
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