P - 82140��-�50-Q22 �
REQUEST FOR ELECTRICAL INSPECTION ��9
Minnesota State Board of Electricity �
1821 UniversiTy Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 �`i
(651) 642-0800 www.electricity.state.mn.us `��'
Home Duplex Apt. Bldg. Other: New Addn
ommercial Industrial Farm Remod Repair
Air Condifioner Htg. Equip. Water Htc Load;,Mgm�. Other:
Dryer Range Elec. Heaf Temp.'Service
"X" above the work covered by this request. Enter remarks in this space and on the back ot fhe white copy only.
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Calculate Inspection Fee - This Inspection Reqvest will not be accepted without the correct fee:
Ofher Installations 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 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL.s.�
Sign / Outline ltg. Xfmr. P���
Alarm/Remote Control
Swimmin4 Pool _ . .
Special Inspe�
Final
Imestigative Fee %d* 3 dv
THIS INSTALLATION MAY BE ORDERED DiSCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS,
OFFICE USE ONLY This request vad 18 months from volidafion date printed in this box.
III�NIHIIl11II�IIIINIINI � ���
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* 0 9 5 0 0 2 2 4* ����
PLEASE PRINT R TYPE
R est Dafe Rough-in inspection required? ❑ Yes ❑ No Inspecfion Other 7han Rough-In: Ready Now ❑ Will Call
"� . You must call the inspector when ready Dafe Ready:
I, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job. ddress (Sheet, Box, or R�t^No.�. A "� - � Zip Code � _
CO 'lJ
Seclion No. Township Name or No.
Occupanf � �
�
Power Supplier
E�fr��EP�ENDABLEy ELECTRIC
Mailin � �1dFBSs (6tiQQ$or ��s o�� P�ing
eon RspiQs, MN 5433
Authoiized Signature or, Company or ner Perf i
' �A-12 E B RD COPY
Phone No.
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ON BACK OF YELLOW COPY