P - 83910REQUEST FOR ELECTRICAL INSPECTION
/� (] ���) Q � Minnesota State Board of El�ctricity
`t �d L V 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone (612) 642-0800 ���
Home Duplex Apt. Bldg. Other: New Addn '
Commercial Industrial Farm Remod e air
Air Cond. Htg. Equip. Water Hir. 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 ihe white copy only.
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Calculate Inspection Fee - This Inspection Requesf will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
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
Sign/Outline Ltg. Xfmr. /C/!�—%�3'�`�7 s�
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins fed the electrical installation described herein on the dates sfated
Irrigation Boom Rough-In Date
Soecial Insoection. � ��
Fee
0
Investigative Fee r�� - �°�d'—S � C%Q
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation date prinfed in this box.
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Request Date Rou h-in ins ection re uired?
g p q ❑ Yes No Inspection Other Than Rough-In: Ready Now ❑ Will Call
`� .,�3_ �� �You must call the inspector when ready) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.� Ci�� Zip Code
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Section No. Township Name or No. Ranqe No. Fire No. Coun n
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IC�Of Of
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Phone No.
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, , Conhactor License No.
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Installafion)
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STATE BOARD COPY - SEE INSTRUCTIONS
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r Lic. No. �Planf Elecf. Only)
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