P - 83500-;�: �
REQUEST FOR ELECTRICAL INSPECTION
5 6 5'� ��� Minnesota State Board of Electricily
1821 University Ave., Rm. S-128, St. Paul, MN 55104
, ;_...;.
r Phone (612) 642-0800
Home - Duplex Apt. Bidg. Other: New Addn
mercial Industrial Farm Remod Re air
Air Co Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer ', Range Elec. Heat Temp. Service
"X" above fhe work covered by this request. Enier remarks in ihis space and on the back of the white copy only.
Calcolate Inspection Fee - This Inspe
Other Fee
Mobile-Home Park Stall
Street Lta./Traffic Siq.
mote Confrol
� Pool
Boom
�n Requesi will not be accepted without the correct fee:
# Service Entrance Size Fee # Circuits/Feeders Fee
0 to 200 Amps 0 to 100 Amps —
Above 200 Am s Above 100 Amps
INSPECTOR'S USE ONLY TOTAL��
I herebvi certib that I inspecfed the elecfrical insfallafion described herein on the dafes stated
'Hl5 INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
-� OFFICE USE ONLY This requesf void 18 months from validation dafe printed in this box.
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� 0' S 6 5 1 3 3- �a * PLEASE PRINT OR TYPE
iest qate � Ro -in inspecfion required? ❑ Yes o Inspecfion Other Than RougMn: Ready Now ❑ Will Call
,.. �� �� ou must call fhe inspecfor when ready� Date Ready:
�nsed contractor ❑ owner hereby request inspection of the above electrical work at:
Adilress �Sheet, Box, or Route No.) ' Ci Zip Code
�. ��J ��
ion.I�o:- Township Name or No. Range No. Fire No. � Counly
�� Phone N� r `� � /
L/t%� / �
Elechical Conhatlor (Company Name� Conhactor License No.
� P� d �JPc�-; c-z'�tr . O I�U
Mailing Address (Conhacto rforming Insfallafion)
3�!Q i'�:;IP.OD LANE
t.
Authorized Sipnahj(�j�onkacf9/x' ner erformiri,q nsta . � . �jr� /� /� .
STATE BOARD COPY - SEE INSTRUCTIONS