P - 82369� �, �-� ; -� . ,
�-99Q�47� �
Apt.
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity 3
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 ��� .
(651) 642-0800 www.electricity.state.mn.us " '
Commercial Indusirial Farm
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. $ervice
"X" above the work covered by ihis request. Enter remarks in this space anc
� �' � ?" �Ii.. l� �� l� d �t1r� � � l� 'i 1 �
��""� va� ��'" 1� +l�� �,� �
Calculate Inspection Fee - This Inspection Request will not be acceF
Ofher Installations fee # Service Enhance ' e Fee #
Mobile Home Park Stall to d
Street Lfg. / Traffic Sig. Above 200 Amps
Transformer/Generator INSPECTOR'S USE ONLY
Outline Ltg. Xfmr.
RerrZVte Control
ing Pooi
I
�n Boom
ihat I
on
Repair
white copy only.
� withoui the correct fee:
�ircuih / Feeders Fee
0 to 100 Amps
Above 100 Amps
described herein on the dafas sfated:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation dafe printed in this box.
I I�I II �I II III II IN N�I lI � INll�l�lll ll 1� l�ll /%/j
* � �� o
0 9 9 0 4? 8 0 * /e--�'�� 7���
PLEASE PRINT OR TYPE
Requesf at Rough-in inspection required? es ❑ No Inspection Other Than RougMn: ❑ Ready tJow 0 Will Call
��a You musf call fhe inspecfor when ready Date Reody:
I, �icensed ontractor ❑ compony ❑ owner hereby request inspection of the above electrical work at:
siw�e evwnu wrr
SEE INSTRUCTIONS ON BACK OF YELLOW COPY