P - 84723457�--194 �
REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New
Commercial Indushial Farm Remod
Air Cond. Hig. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above e work covered by is req si. Enter remarks in ihis space and on the back of the white copy c
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Calculate Inspectio ee - This Inspection Requesi will not be accepted wiihout the 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 Amps Above 100 Amps
Transformer/Generator �NSPECTOR'S USE ONLY TOT�A
$ign/Oudine Ltg. Xfmr. � �'%�
Alarm/Remote Control
Swimming Pool
I hereb certi ihat I ins fed the elechical installafion described herein on the dafes sfated
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Fee
THIS INSTAILATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 16 months from validation daM printed in fhis box.
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* � 4 5 7]� 9 4 9�K PLEASE PRINT OR TYPE
Requesi Date Rough-in inspeclion required$ ❑ Yes o Inspeciion O�er Thon RougMn: eady No ill Call
(You must call the inspector when ready) Dofe Ready:
I, licensed conhactor ❑ owner hereby request inspection of the above elechical work at:
Job A es Sheet, x, or Roufe No.) f � C; P
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Section No. Township Name or No. Range No. Fire No. Counry
Occupanf
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Power Su �
Eledrical n r (Compa e)
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Mailing Add�ess (Conhactor or Own P rrt
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Authori Siga �(Con or or Owner�
Conhaclor
Phone No.
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Masfer lic. Na (Plant Ele�
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- SEE INSTRUCTIONS pN gpCK OF YELLOW COPY