P - 81233�02°163 �
Commercial Industrial
�ir Cond. Htq. Equ
"X" above the work
RE(�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-12S, St. Paul, MN 55104 �
Phone(612)642-0800
Apt. Bldg. Other: New Addn
Farm Remod Re air
Water Htr. load Mgmt. Other:
Elec. Heat Temp. Service
►his reqvest. Enier remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will noi be occepted wifhout fhe correct fee:
Other fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stafl 0 to 200 Amps 0 to 100 Amps
Street Ltg./TrafFic Sig. Above 200 Am s Above 100 Amps
TransFormer/Generator INSPECTOR's use oN�r TOTAL
Sign/Oudine Ltg. Xfmr. �� Nq L �J�t R� ���-Z � I
Alarm/Remote Conhol ? j/ ��� a�1 �
O
Swimming Pool Q `i
I hereb ceAi � I ms Ihe eleclrical inslatlation described herein on ihe dales stoted
Irrigation Boom RougMn ��
Special Inspection
Fee
`�c
Final � � ����
Imestigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTF{S.
OFACE USE ONLY This roquesf void 18 monlhs from volidafion date printed in Ifiis box.
Ilil���l�l�����������������l� � � af'�
I�I�li�l�i��l�i
* 0 8 0 2 1 6 3�* �� �°Z
PLEA E PRINT OR TYPE
Request Dafe � Rough-in inspeciion required$ ❑ Yes o Inspection Other Than Rough-In: � Ready Now � Coll
� �� (You must call the inspector when ready� Date Ready:
I, ❑ licensed contractor owner hereby request inspection of the above electrical work at:
Job Address (Skeet, Box, or Ro�ug No.) City �r Zip Code
7� ��� C.�Al�i�AL- x Y�/fi� �
Occupant
�
Power Su�
or
(Conhacfor or Owner Performing
— .� � • .
STATE BOARD
Range No. Fire No. C�nly �
� �
Phone No.
d,��'1,�J� �/�-�
Conhacfor License No.
�, ,
Master Lic. No.
i
INSTRUCiIONS ON BACK OF YELLOW COPY