P - 83625REQUEST FOR ELECTRICAL INSPECTION
4�.l �= 7 6 7 MinResota State Board of Electricity
1821 Universiiy Ave., Rm. S-128, St. Paul, MN 55104
i Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New
Commercial Industrial Farm Remod
Air Cond. Htg. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this req�est. Enter remarks " ihis space and on the back of the white copy
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Calculate Inspection Fee - This Inspection Request will not be accepted without fhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Ar
Transformer/Generator INSPECTOR•s use oN�v TOT�
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control �
Swimming Pool
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Fee
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I hereb cerh thof I ins the eleclrical insfallation deuribed herein on the dates sfafed
Irrigation Boom Rough-I� pa�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF N0T COMPLETED WITHIN 18 MONTHS.
- � OFFlCE USE ONLY This request wid 18 months (rom validafion dafe prinfed in ihis box.
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PLEASE PRINT OR TYPE
R Dafen.'_ y.�, Rough-in inspecfion required2 ❑ yes o Ins hon Ofher Than Rou Mn: Read Now
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I, . licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
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S E BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW
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Lic. No. (Planf Elecl
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