P - 81248� REQUEST FOR ELEC .� INSPECTION ��":�°'��
�' 1 � Mir,nesota State Board of Electricit `�.a
�'.� 1-19 5 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 ihe work covered y this request. Enter remarks in this space and on
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ite copy
Calculaie Inspecfion Fee - This Inspection Request will nof be accepted without the correc�''r�e% o"`� �/lut �
Other Fee # Service Entrence S'ze Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Am s 0 to 100 Am s
Street Ltg./TrafficSig. Above204' Am s Above'T66- Amps . li
Tr n er/Generator _ INSPECTOR'S USE ONLY TOTAI�ri �
Sign/Out{ine Lig. Xfmr. � i
Alarm/Remote Control
Swimming Pool -
I hereb
Irrigation Boo RougMn
SnArinl�lncnar+i�n ... .
that I inscecled the elscfrical installation described herein on
Investigative Fee � �C— C�' )`
THIS INSTALLATION MAY BE ORDERED DISCO D IF NOT COMPLETED WI HIN 18 MO HS.
OFFICE USE ONLY This requesf void 18 month� validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Rough-in inspecfion required? ❑ Yes o Inspecfion Other Than RougMn: ❑ Ready Now ill Call
✓ � (You musl call the inspector when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Addr Sheef, Box, u ^ City Zip Code
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Settion No. Township Name or No. Range No. Fire No. Counly �� ,^
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STATE B ARD COPY - SEE
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Phone No.
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ON BACK OF YELLOW COPY
Elect. Only�
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