P - 84500RE(�UEST FOR ELECTRICAL INSPECTION - �
'�+ ��= 2 2 7 Minnesota State Board of Electriciiy
1821 University Ave., Rm. S-128, St. Paul, MN 55104
' Phone (612) 642-0800
Home Duplex Apt. Bidg. Other: New Addn
Commercial Indushial Farm emod Re ir
Air Cond. tg. Eq ' Water Hh. Load Mgmt. Other:
�Dryer ang (1 Elec. Heat Temp. Service
"X" above the work covered by this request. Enier remarks in this space and on the bnck of the white copy only.
Calculate ►nspection Fee - This Inspection Request will noi be accepted without the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
�ign/Oudine Ltg. Xfmr. '� 5
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins ted fhe electrical installation described herein on the dates stated
Irrigation Boom Roo9 i� � p ��� CJ
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN i8 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation dafe printed in fhis box.
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* � 4 4 8 2 2 7 9* PLEASE PRINT OR TYPE
Request Dafe Rou h-in ins fion r uired? Yes ❑ Rea No Will Call
g pec eq ❑ No Inspection Other Than RougMn: dy
3�.. O,..� � (You must call the inspecfor when ready) Dafe Ready:
I, icensed conhactor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheef, Box, or Roufe No.) City Zip Code
i Sr j2 ,a�--`e
Secfion No. Township Name or No. Range No. Fire No. Co ty
� D�i/�
Occum� Phone No.
Power Supplier 1
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or Vwner rertorrt�f
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY