P - 80648, REQUEST FOR ELECTRICAL INSPECTION
��,� �(� 1� � Minnesota State Board of Electricity �
`�^� J 1 1821 University Ave., Rm. S-128, St. Paul, MN 55104
. Phone (612) 642-0800 '� �
Home Duplex Apt. Bldg. Other: New A�
Commercial Industrial Farm Remod Re
Air Cond. Htg. Equip. Wafer Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in ihis space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not 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 Am s Above 100 Amps
T�ansfo�mer/Generator INSPECTOR�s use oN�v TOTAL _
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Ih
(rripation Boom v�
that I ins fed the eleckical insMllation described herein on the daMS slafed
Date
. • Final
Investigative Fee g � 7 --
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validafion dafe prinfed in this box.
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PLEASE PRINT OR TYPE
Requesf te Rough-in inspecfion required$ ❑ Yes No InspecKon OtherThan RougMn: ❑ Ready Now Will Cal)
�— (You must call the inspecror when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above elecMical work at:
lob Address �Sheet, Box, or Route No.) Ciy Zip Code
�t t5 � I�C�eXto ��r%a, 55�3Z-
Section No. Township Name or No. Range No. Fire No. Co y
Occupant
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Power Supplier , Address
e��h��a� cBk�111����i.�i`�+ ELECT., INC C000-o�ror
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Mailing Address Cp�ppqfix��rpi�p Insfallafion) �
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Phone No.
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BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY