P - 84256� ;�;1�-224
REQUEST F ELECTRICAL INSPECTION
Minnesota St e Board of Electricity
1821 Univ ity Ave., Rm. S-128, St. Paul, MN 55104
Phone ( 2) 642-0800
Home Duplex Apt.8ldg. Uther:
Commercial Industrial Farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other.
Dryer Range Elec. Heat Temp. $ervice
„X„ above the work covered by this request. Enter remarks in this space anc
New
on the back of the white copy
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Calculate Inspection Fee - This Inspection Request will not be accepted withoui 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 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Oudine Ltg. Xfmr. � � - ��
Alarm/Remote Confrol
Swimming Pool
I hereb certi fhat I ins ted fhe elecfrical installation described herein on the dates siafed
Irriaation Boom e�,�„�.i„ Dare
Investigative Fee " ; -'- " 6
THIS INSTALLATI6N MAY BE ORDERED DISC NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validation dafe printed in fhis box.
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PLEASE PRINT OR TYPE
Request Dafe Rougifin inspecfion required? ❑ Yes No Inspection Ofher Than Rough-In: ❑ Ready Now ill Call
l� ��—� � (You must call the inspector when ready) Date Ready:
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I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
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Job Addreu Streef, Box, or Route No.) City Zip Code
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Secfion No. Township Name or No. Range No. Fire No. County
Occupant
cT�G� n�� r va.r� i�i�
Power Supplier Address
Mailing Address
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Phone No.
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Conhactor License No. Master Lic. No. �Plant Elecf. Only�
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ing Installation) �( q� Phone No.
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CO - SE NSTRUCTIONS ON BACK OF YELLOW COPY