P - 81489REGIUEST FOR ELECTRICAL INSPECTION
6(�f� � n[ 3 Minnesota State Board of Electricity
.s it .,J 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New
Commercial Industrial Farm Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ►his request. Enter remarks in Ihis space and on the back of the white copy c
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Calculaie Inspection Fee - This Inspection Request will not be accepted wiihout the correct fee:
Other Fee # Service Entr Size Fee # Circuits/Feeders
Mobile Home Park Stall � 0 to 00 A �$ �j�� 0 to 100 Amps L
Streef Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Oudine Lfg. Xfmr. �
Alarm/Remote Control
$wimming Pool
I hereb certi that I ins ed fhe elecirical installation described herein on the dates sfafed
Irrigation Boo RougMn Date
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Fee
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Investigative Fee ��� � �"�— (i ' � ^ l
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months from validation dafe printed in this box.
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LEASE PRINT OR TYPE
Requesf Dafe RougfFin inspection required$ ❑ Yes o Inspedion Ofher Than Roughan: ❑ Ready Now Will Call
� (You must call the inspecfor when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addreu (Sheet, Box, or Route No.) Ci Zip Code
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Section No. Township Name or No. Range No. Fire No. Counly �
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E'�`h`°°' `°"�°�`�L`�"�`1`I�IC SERVICES
Mailing A r r mi I io �
Aufhorized Signature �Conhacfor or Owner erforming Insfai atic
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E&00001 A-1 1 8/96 STATE BOARD P-:
Phone �o. �
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Master Lic. No. (Plant Elect. Only)
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Phone No.
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INSTRUCTIONS ON BACK OF YELLOW COPY