P - 82991, REQUEST FOR ELECTRICAL INSPECTION
4 4�� - 6 5 0 Minnesota State Soard of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (512) 642-0800
ome Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requgst. Enter remarks in this space and on the back of the white copy only.
.��-� .�-�� �
Calculate Inspecfion Fee - This Inspection Request will noi be accepted without the correct fee:
Other Fee # Service Entrance Size fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins ted the elechical installa6on described herein on the dates sk
I' B
Fee
�
rngation oom RougMn Dare
Speciallns - �
Final
Imestigative Fee .- --
THIS INSTALLATION MAY BE ORDERED DISCO CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFflCE USE ONLY This request void 18 months 6om validafion date printed in fhis box.
iiili�l�ll���llliilliiiii iiiiii iii • ��
II �II�II ..�
*0�+�9�so1* l
PLEASE PRINT OR TYPE
Request Date R h-in ins
oug pecfion�required? ❑ Yes �❑ No Inspecfion Olher Than RougMn: Ready Now
❑ Witl Calf
ou musf call the inspecfor when ready) pa�e Read�,:
I, licensed contractor ❑ owner hereby request inspection of the obove elecfrical work at:
Job �ess �Streg�, Box, or Roufe No.) � City�� � � Zip Code
/J ,!1 .i
, .�.�� �. , .c � L , r Z_._
or No. Ra ge No. fire No. Ce,���
OccupaM
� Ld
Power Suppiier
�
Electrical Conhac�« (Compony Nai
Mailing Address � pntractor or Ow
V ✓
AufFroriz Si re (Conhacfor or
�` Phone No.
T"— !
Address � � � � �
coo�.�/TUicense No. Masrer li�. No. (Plonr elecr. onh/)
/
nlla' �
�d S s' � 7
ilnsmllatio � Phone No.
1
3�.��'
COPY - SEE IN ONS ON BA K F YELLOW COpY