P - 83883.���-841 �
RE(�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
New
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Commercial Industrial Farm Remod Re
Air Cond. tg. Equip. Water Htr. Load Mgmt. Ofher:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted withouf 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 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �
Sign/Outline Ltg. Xfmr. ��•
Alarm/Remote Control
Swimming Pool
Irripation Boom
that I ins ted the elechical installation described herein on the dates stafed
Dafe
' Final D �
Investigative — �
THIS INSTALLATIO __ E ORDERED DISCO _ ED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requestvoid 18 monfhs from validafion dafe prinfed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rou h-in ins tion r uired?
g pec eq ❑ Yes �, o Inspecfion Other Than RougMn: 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 Address (Street, B x, or Roufe No.) City Zip Code
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Section No. Township Name or No. Range No. Firc No. County
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or Owner
Phone No.
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Master Lic. No. �Planf Elect. Only)
Signature ontractor or er erforming Inst ation) �` Ph e o. �(���
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1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BAC F YELLOW COPY