P - 84574.
� 4 �°233
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Home Duplex
Commercial Industrial
� "X" above the work
Calculate Inspection Fee - This Insp
Other Fee
Mobile Home Park Stall
Street Ltg./Trar`fic Sig.
Transformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �;
Phone(612)642-0800
Other: New Addn
Farm
Water Hfr. Load Mgmt. Other:
Elec. Heaf Temp. Service
request. Enier remarks in this space and on
the white copy only.
m Request will not be accepted without ihe correc► fee:
# Service Entrance Size Fee # Circuits/feeders Fee
to 00 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TQTAL �'.�[�
S �� _ t�.—'
I hereb certi thai I ins ted �e electrical "nstallafion described herein on Ihe dotes staled
(rrigafion Boom eoogM� par � q
Special Inspect , '" — l
Final � pa�
Investigative Fee .- �7 "
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months 6om validation date prinfed in this box.
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* 0 4 4 8 2 3 3 7* ��
PLEASE PRINT OR TYPE
Requesf Date �� Rou h-in ins on r uired? Yes
�� g pecti eq ❑ No Inspection Olher Thon RougMn: ❑ Ready Now Will Call
�L�� (You must call the inspector when ready) Dafe Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Sheei, � or R te No� � Ciy � Zip Code
�
Secfion No. Township Name or No. Range No. Fire No. Counly
Occu . � _ � � Phone No.
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Nlailing Addresg �Conhactor or � Per(o���tion�
�. �' • Cl f"' � �
Lic. No.
Installafion) � � - — ' — � Phone No.
t. Only)