P - 83335REQUEST FOR ELECTRICAL INSPECTION °'E
6 p� 9(� ` � Minnesota State Board of Electricity
c? ll La 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
� Phone(612) 642-0800 "�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range E{ec. 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.
Calculate Inspection fee - This Inspection Requesi wiil not be accepted without 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 i TOTA
Sign/Oudine Ltg. Xfmr. ���,,,g..� �/y-1 �t c�° 4�
Alarm/Remote Co hol
Swimming Pool
f hereb certi Ihal I ins lhe elechical inslallafion dexribed herein on the dofes sfated
Irrigation Boom RougMln Dare
Special Inspection
Investigative Fee F�� ��� D^ Z'L
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 monfhs From val' ation dafe printed in this box.
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* 0 6 8 9 9 0 6 6* lS"�U
PLEASE PRINT OR TYPE
Requesf Date Rough-in inspection required8 ❑ Yes o Inspecfion Other Than Rough-In: eady Now ❑ Will Call
A �� �You must call the inspecror when ready) Dafe Ready:
I, icensed conhactor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Skeef, Box, or Roufe No.) Cily � Zip Code Q�
1(<iCl �� � �J / /�Ii �� ��`./
Secfion No. Township Name or No. Range No. Fire No. uny
f'(�
Occu Phone No. .
.�e� � �� �u �ec� � ��1-���gs�
;lor (Company Name� Con
zwK ��,.�c_`� 7 �,
�CoMrador or Owner PerForming Installation)
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STATE BOARD COPY - SEE INSTRUCTI ON BACK OF YELLOW COPY