P - 84628/� REQUEST FOR ELECTRICAL INSPECTION -_
_�# J 5� 2 O 6 Minnesota State Board of Electriciry
- 1821 University Ave., Rm. S-128, St. Paul, MN 55104 -
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indushial Farm Remod Re ir
Air Htg. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" a6ove the work covered by ihis request. Enier remarks in this space and on the back of the white copy only.
Calculafe Inspection Fee - This Inspe
Other Fee
Mobile Home Park Stoll
Sfreet Ltg./Traffic Sig.
Tra nsformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irripation Boom
>n Request will not be accepted without the correcf 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
the elechical installafion described herein on the
Investigative fee�( J a ...�. ""� �. 3.- oc
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 moMhs (rom validafion date printed in this box.
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PLEASE PRINT OR TYPE
Request Date R h-in ins on r uved?
ag pecfi eq ' ❑ Yes o InspecKon Olher Than ougMn: Ready Now � Will Call
(You musf wll Ihe inspecfor when ready� Dafe Ready:
I, �licensed confracfor ❑ owner hereby request inspection of the above electrical work at:
.bb Address (Street, x, a Roule No.) _ City : Zi C
3 ��'' �� �' ° /� �`'�' e : ��'t/�
Secti n No. Township Name or No. Range No. Fire No. County/ '^ !�
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Power Sw
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mpany Name) Contry� �L�cens�.LJo Master lic. No. (Plant Elect. Only)
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