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� Home Duplex
REC#UEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity � �1�
1821 University Ave., Rm. S-128, S�ul, MN 55104 x'���� '
Phone (612) 642-0800 .----.—�„ ��
�. Other. �—� New Addn
Commerciol Industrial Farm Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer �ange Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the whife copy only.
Calculate Inspection Fee - TFiis Inspection Request will not be accepted without fhe correcf fee:
�Dther Fee # Service Entrance Size Fee # Circuits/Feeder� 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 TOT�L
S
Sign,�0utline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pcol
— I herebvi certifv that I inscected Ihe elechiml installation described he�ein on the dutes stated
Final Dote
Investigative Fee
T[il� it�fSTALIA.TltiN R9AY BE ORD�RED DISCONNEGTED IF NOT COMPLETED WITHIN 1R MO►�1TNG.
� � OFFlCE USE ONLY This requesf void 18 months fr �dation date prinfed in thi
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�._El�ll III II III II I� II III 11III II III II III II III I IIII � -
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"� �"--4 9 8 9 5 2 L* .. pLEASE PRINT OR TYPE
i:�Request Dvle .. � , Rou hin ins lion r uired$ Yes
g pec _ eq ❑ No Inspeclion Other Than RougMn� ❑ Ready No Will Ca1 �
i.-. __ � �You musEcall lhe.inspectorwhen ready� Da1e.Ready: �- `!
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1, icensed contrdctor ❑ owner hereby request inspection of tfie. above`electrical work at: �
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F �� Job Address(Str , Box, or Route No.) ° � �� � Cify � � �-� - � Zip Code � � -
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�': -` Secfion No. Township Name or Na .� Range No. Fire No: -- � Coun � �
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�� Power Supplier
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- Electrical ConhpF� rRge��� ��
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' ` 310C,-22� fH ST. W.,
� Mailing Address �Conkacfor or Ow r Perfa
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I�� � Authorized Sig ture �Contra or � er
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� Phone No. �
6-? � � � S
Address
Coniractor License No. Master lic. No. (Plant Ele�
TN., MN 55024
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