P - 81244REQUEST FOR ELECTRICAL INSPECTION
�0 �= 6 4� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: Addn
Commercial Industrial Farm emod Re
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered b this request. Enter remarks in this space and on the bPck of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepied witho ihe 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
Transformer/Generator INSPECTOR'S USE ONLY TOTA ��
Sign/Oudine Ltg. Xfmr. � � � � �
Alarm/Remote Confrol
Swimming Pool
I hereb certi fhaf I ins the electrical insfallation described herein on the dates stated
Irrigation Boom Rough-In � Dare ,� �� L
...._.
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED W IN 18 MO S.
OFFICE USE ONLY This roquest wid 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
quest Dafe � Rough-in inspeclion required? ❑ Yes
❑ No Inspection Olher Than RougMn: ❑ Ready Now ❑ Will Call
(You must call the i�specror when ready) Oafe Ready:
cens contractor ❑ owner hereby request inspection of the above electrical work at:
� Address Skeef, Box, or No.�� Cily � Zip Code
( / -��1.., `� i
dion No. i nship Name or No. Range No. Fire No. Counfy.
Occupan�Cr/� / (
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Power Supplier
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Elechical Conhacfor �Compa y
Mailin� Address �Conkactor or Owi
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Au �riz Si (Conh tor or
1 1 8/96
� � r � A � � O Phone N� ^� � � � 1-
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� Address
!) Conh cior License No. Masler Lic. No. (Plant Elecf. Only��
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:r Performing Insta on
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erfo g s fi - Phorie No.
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iTAT B ARD COPY - SEE INSTAUCTIONS ON BACK OF YELLOW COPY