P - 80218REQUEST FOR ELECTRICAL INSPECTION ��,���.o
,�^(/}�( 1 77 Minnesota State Board of Electricity �'
U� V�,J ��-L 1 1'� 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
� ` (651) 642-0800 www.electricity.state.mn.us "�'
Home Duplex Apt. Bldg. Ofher: New Addn
Commercial Industrial Farm Remoci Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this re uest. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request wil n�acceptedC� the c��ec�fee: ��� �
Other Installations Fee # Service Enhance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / TrafFic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL `
Sign / Outline Ltg. Xfmr. �+ J
Alarm/Remote Control
I hereby cerT7(y that 1
� � Investigative Fee � � � _ ��%� �
THIS INSTALLATION MAY BE ORDERED ONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� �� OFFlCE USE�ONLY This request void 18 monfhs from vali fi dafe printe m this box.
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PLEASE PRINT OR TYPE �
Requesf Date Rough-in inspecfion required$ ❑ Yes No Inspection Other Thon Rough-In: ❑ Ready Now ill Call
2. ���� You must call fhe inspector when ready Date Ready:
I, �licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Ad ress (Street, Bo or Route No.1 \ Ciry Zip Code
..e S � 2
Section No. Township ame or No. Range No. Fire No. � Co�i y __/� _
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� 'NC. I Coqjrpct��s� No. � ��
�VE. N.E. � r �--�i
r Performing Installation)
ire Con aMor, o an or Owr�r Performing In � Phone Number
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,.__... ��ST/ATE �BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW Cn°'