P - 84008RE(�UEST FOR ELECTRICAL INSPECTION
5 2?�- ��� 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 Indushial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this request. Enter remarks in this space and on the back of the whiie copy only.
Calculaie Inspection Fee - This Inspection Request will nof be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders 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�
Sign/Outline Ltg. Xfmr. � �—
Alarm/Remote Conhol
Swimming Pool
I hereb certi thaf I ins ed the elecfrical installafion described herein on fhe dafes sfafed
Irfi9ation Boom RougMn Date
Speciallnspect �`
Final �
Investigative Fee "'�
THIS INSTALLATION MAY BE ORDERED NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months from validation date printed in this box.
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�K � 5 2 2 9 1 L 7�k PLEASE PRINT OR TYPE �S ��
Requesi Date Rough-in inspection required? Yes ❑ No Inspecfion Other Than Rough-In: Ready Now ❑ Will Call
'`„ � O �q� (You must call the inspector when ready� Date Ready:
I,�licensed contractor ❑ owner hareby request inspection of the obove electrical work at:
Job Address �Street, Box, or Route No.) Ciy � Zip Code
� � '
Secfion No. Townzhio Name or No. Ranpe No. Fire No. Couny
mt Phone No.
Supplier ^ Address
S�
al Contracfor �Company Name) '��ES ��'C"�� � Conk� No. Masfer Lic.
310G-??STi� 8T. Y�, FG MN b6Q2�
3 Address (Confrador or Owner Perf ri g Installafionr � �
Signature (Conhactor or Owner Performing �nstallafion) (/ � v[� �� I Phone No.