P - 82699REQUEST FOR ELECTRICAL INSPECTION
�� C���(� �� Minnesota State Board of Electricity
v 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �;
Phone (612) 642-0800 '�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. L Mgmt. Other:
Dryer Range Elec. Heat emp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculaie Inspecfion Fee - This Inspection Request will not be accepted wifhout fhe correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park $tall 0 Fo 200 Amps 0 ro 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer�Generator INSPECTOR'S USE ONLY TQ�AL �
Sign/Oudine lfg. Xfmr. �� �
Alarm/Remote Conhol
Swimming Pool I here certi thaf 1 in the elechical inslallation described herein on the dates stated
Irrigation Boom Ro„9M„ p�
Special Inspectio ' ! �
� Final DaTe ^�
Investigative Fee � ��Z " (
THIS INSTALLATION MAY BE ORDERED DISCONN CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OF'�E USE QlILY This reQuest vad 18 months from wlidafion date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Date Rou h�in ins eq specfion Olher Than Rou h-In:
1^ _^ g pection r uired$ es ❑ No In g ❑ Ready Now ill Call
���r �You must wll the inspecto� when ready) Date Ready:
I, licensed contractor ❑ owner hereby requesi inspection of �Zectr' I ork at:
Job Address (Sheet, Box, or Ro�fe No� C� C�e
� Y5' � lfl? � ST� So�v C�'.
Secfion No. Township Name w No. Range No. � Fire No. Cou �
�0�� Phone No. ,
�
Power Supplier � � Address �
�
C�' I Contractor License No. I qAasfer lic.
�
�Conhacbr or Owner
� �
Installafio 4 8 9 9 Phone No.
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLO