P - 83456, '� I C7��OV �
REQUEST FOR ELECTRICAL INSPECTION p1e
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Other: New Addn
Commercial Industrial Farm Remod
ir C Htg. Equi . Water Htr. load Mgmt. Other:
� ry� Rang Elec. Heat Temp. Service
"X" abov e work covere y this request. Enter remarks in this space and on the back of the white copy only.
Calculaie Inspection Fee - This Inspection Request will not be accepted wilhout the correct fee:
Other Fee # Service Entrance ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T4TAL _
Sign/Outline Ltg. Xfmr. L
Alarm/Remote Control
Swimming Pool
I herebvi cem'fv that I insoecled the electrical installation deuribed herein on the
Invesfigative Fee � � C ��y`��_�����
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WI7�iIN 18 MONT S.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rou h-in ins on r uired? Yes
' I^ � g pecli eq ❑ No Inspection Other Than Rough-In: ❑ Ready Now Will Call
(You musf call the inspeclor when ready� Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, Roure No.) Ciy Zip Code
� �
Section No. Township Name or No. Range No. Fire No. C n
Phone No.
0
(Company Name) � Conhacfor License No. � Masfer Lic.
f� 1 ^�,R1n'N �
� _ - � 6;;:,� �� I
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY