P - 81635REQUEST FOR ELECTRICAL INSPECTION
8 O'L - 2 41 � Minnesota State Board of Electricity '3
1821 Universiry Ave., R. S-1 , St. Paul, MN 55104 -
, ' Phone (612) 642-0800 � �� "°�'
Home Duplex Apt. Bldg. Other. J Q�� New Addn
Commercial Industrial Farm �� �j 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.
Calculate Inspection Fee - This Inspecfion Request wili not be accepted without the 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 TOTAL / �
Sign/Outline Ltg. Xfmr. , O �l i� O
Alarm/Remote Control ���"�� ���"��
Swimming Pool
I her certi thot I ins ed the electrical insmllation dexribed herein on ihe dates stated
Irrigation Bo e RougMn Date
Speciallnspection - '� a�
Investigative Fee Final Date _ `�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFRCE USE ONLY ihis request wid 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Reques Date Rough-in inspection required? Yes ❑ No Inspection Other Than Roughan: dy
❑ Rea Now Will Call
S" Q �You must mll the inspecror when ready) Date Ready:
I, ❑ licensed contractor � owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Rouk No.) Ciy Zip Code
�l s� Fi�,c�.ie s�/3Z
Secfion No. Tow ip Nome o�0 Rang�o. „ Fire No. County��D �
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Occupanf
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Power $upplier
Elxfrical onhactor (Co pa
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Mailing Address�f.aptracror or
859��
Phone No.
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Conhacfor License No. Masfer Lic. No. IPlanf Elecl. On
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INSTRUCTIONS ON BACK OF YELLOW COPY