P - 82899REQUEST FOR ELECTRICAL INSPECTION
���-12 3 Minnesota State Board of Electricity
,, 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800 `'�'
Home Duplex Apt. Bldg. Other: New
Commercial Industrial Farm Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other.
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesi. Enter remarks in this space and on ihe back of the white copy
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Calculate Inspection Fee - This Inspection Request will not be accepted without ihe correct fee:
Other Fee # Service Entrence Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 2Q0 Amps 0 to 100 Amps
$treef Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator NiSPECTOR'S USE ONLY TOTAI�
Sign/Outline Ltg. Xfmr. `�
Alarm%Remote Confrol
Swimming Pool ��ebvi certifv ilwt I i�spected the elechiwl installation descri6ed herei� on the dates statE
Rough-In � �re
Fee
�O
0
Investigative Fee L�'`'"'�1 `�-`�'�'C�
THIS INSTAILATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 monfhs from validation date printed in this box.
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PLEASB PRINT OR TYPE
Re�uesf Date Rough-in inspectio� raquired? ❑ Yes o Inspection OYher Thon RougMn: �'�eady Now � Will Call
�- "� �You must call the inspecfor when ready) Dafe Ready:
I, �iicensed contractor ❑ owner hereby request inspection of the above electrical work at:
J;b� �drfes\s (St�eet, B/ox. j r Route ,o.) , Cily � � '� Zip Code
� �i'�l c� l �
Harri
Mailing Addre
or No. I Range No. � Fire No.
Electric, Inc.
or or Owner PerForming Installafion)
da Avenue North
1 �
BOARD COPY - SEE
PJn^ � 11 . J t!J �
Conhacfor License No. Masfer Lic. No. (Planf Ele�
CA00808
O1 Golden Valle� 55427
Phone No.
' S44-3300
ICTIO CK OF YELLOW COPY