P - 83038" REQUEST FOR ELECTRICAL INSPECTION ::a�
6��r'j � Q Q� � Minnesota State Board of Electricity
L O 0 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
� Phone (612) 642-0800 '�'
Home Duplex Apt. Bldg. Other: New Addn
ommercial Industrial Farm Remod Re air
ir Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the whi►e copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Fecders Fee
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 T
mote Confrol
� Pool
Boom
installaKon described herein on the dafes staled
Dare
� THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This request void 18 months from validation date printed in ihis box.
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* 0 6 6 2 8 8 4 6* ���
LEASE PRIIdT OR TYPE
Request / Rough-in inspection requiredZ ❑ Yes No Inspecfion Olher Than RougMn: Ready Now � Will Call
�� (You must call the inspecror when ready) Date Ready:
I licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job A dress Sheef, Box, or R No.) � City / Zip C
�
Secfion No. Township Name or No. Ran e No. Fire o. Counly
Occupant ``��I� Phone . ,J } ��
G % /�
Power Supplier Address
Elechical Conhacror (Company Name) � Co a 'ce se MasMr Lic. No. (Plant Elect. Only)
�1�D aG O�� •�F�i. li�lie / ,
M�g4� m' IOf ) '
b1�2 W�a� �$'4'::�.D 1'�� i� L� . r
�G V
� � 2
��,�ormin stall � Phone No.
STATE ARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY