P - 84216I 49.�-106 �
RECIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Other: New
Commercial Industrial Farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. En►er remarks in this space anc
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Remod
on the back of the white copy
Calculate Inspection Fee - This Inspection Requesi will not be accepted wiihout the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Am
Transformer/Generator INSPECTOR'S USE ONLY TOTA
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi fhaf I ins ted the elechical installation described herein on fhe dates
Irriaation Boom a„��„ti_i„ Date
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Fee
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Final � i ate
InvestigativeFee � ----"'__""."°,.-. 7_ 3 --��
THIS INSTALLATION MAY BE ORDERED DISCONNEGTED IF NOT COMPLETED WITHIN 18 MONTHS.
OPFICE USE ONLY This request void I B months From validation date prinfed in this box.
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Requesf Date Rough-in inspection required? ❑ Yes No Inspecfion Ofher Than Rough-In: ❑ Ready Now
��, �„� g (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, Box, or Route No.) City Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Cou �
Occupanf
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Phone No.
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Conhacfor License No.
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fvloster Lic. No. �Plant Elecf. Only)
Phone ^N`o^. (�
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COPY