P - 81754REQUEST FOR ELECTRICAL INSPECTION
� o L� L�� � Minnesota State Board of Electriciry \
1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 2-0800 , ��
Home Duplex Apt. Bldg. Other: �� C, ew 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 request. Enter remarks in this space and on the back of the white copy only.
Cakulate 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 •/ to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S US/E O�NLV / TOTA�� �0
Sign/Oudine Ltg. Xfmr. ��L+�t G-�.v—�� �
Alarm/Remote Conhol ��jEj� �
Swimming Pool I hereb certi thaf I ins `the e� ical ins�described herein on the dafes staled
Irrigation Boo RoogMo qate /� Q�
$pecia) Inspec on • G"
Find � �z () -r CCy
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISC ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months 6om validation date prinfed in this box.
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PLEASE PRINT OR TYPE
Requesf . fe R�Mn inspecfion required? es ❑ No Inspection Other Than RougMn: ❑ Ready Now Will Call
��D � a� (`/ou must mll the inspecror when r dy) Date Ready:
I, ❑ licensed contractor owner hereby request inspection of the above electrical work at:
Job u �Sh Box, o�r le No.� Ciry Zip C
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Secfion No. Township Name No. Rang�� Fire No. County����
Occupont �-` / ^ j phone No.
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Power Supplier - Address
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Elechical Contrac pany Name) Conhacfor License No. Master Lic. No. (Planf Elecl. Only)
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Mailing Address (Co r or Owner PerForming InsfallafiCn� .,
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Authorized ' nalure (Confracfo� or Own Performing I afall n� Phone No.
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E A- 8/96 ATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY �