P - 80726REAU�ST FOR ELECTRICAL INSPECTION
�1�, � 3� 6 Minnesota State Board of Electricity
�''` � 1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104
� Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
, Commercial Industrial Farm Remod Re air
� Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in �is space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspeciion Request will not be a pted without 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 oN�v TOTAL
Sign/Outline Ltg. Xfmr. ,;, {3,
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I herebvi certifv that I
described herein on the dates staTed
Date
Imestigatrve te�—� — F
THIS INSTALLATION MAY BE ORDERED DISCONNE NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validafion dafe printed in fhis box.
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PLEASE PRINT OR TYPE � "
Request Dafe Rough-in inspeclion required? ❑ Yes No Inspection Ofher Than Rough-In: ❑ Ready Now ill Call
i (You must call the inspector when ready� Date Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or Route No.) Ci Zip Code,
2d . idl�. ;S�{a l
Secfion No. Township Name or No. Range No. Fire No. County �
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Conhacior
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EI..ECT., fNC.
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fn���Owner Perfor�ng Instol�afion) i� PI
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