P - 84007RE(�UEST FOR ELECTRICAL INSPECTION ��
5��� Q�� � Minnesota State Board of Electricity
`� 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. Load Mgmt. Oiher:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be
Other Fee # Service Entrance
Mobile Home Park Stall to 200 Amps
Street Ltg./Traffic Sig. Above 200 �
Transformer/Generator INSPECTOR•s use oN�v
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins te
Irrigation Boom Rough-In
Special Inspec n � �
without the correct fee:
Fee # Circuits/Feeders
0 to 100 Amps
Above 100 Amp:
TOTAL
the elecfrical installation described herein on }he dafes stafed
Dafe
Fee
Final ! D q
Investigative Fee G (
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 monfhs from validafion dafe prinfed in fhis box.
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IIIII ulll IIIII III�I IIII) I��) IIIII IIIII IIIII �� 3��
* � 5 G� 2 9 � 9�* PLEASE PRINT OR TYPE =�J`'S
Request Date Rough-in inspeciion required? ❑ Yes ❑ No Inspeciion Ofher Than Rough-In: dv Now ill Call
, I.� y� 7 (You must call the inspector when ready) Date Ready:
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I,' icensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Sireet, Box, or Route NQ;) City
����
Seciion No. Township Name or No. Range No. Firc No. Coun ��
Power
S
�'°`'''�"v� ��c• CA00381
''� �T W., �G TAl., MN 55024
or Ow Perfonying I�sta ahon)
Signature (Contractor or Owner
Phone No.
Master Lic. No.
EB-00001 A-i l S/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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