P - 80631`_` � � �� � ��"b REQUEST FOR ELECTRICAL WSPECTION �
,� ���� Q� � Minnesota State Board of Electricity
`� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone (612) 642-0800 " '
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other.
Dryer Range Elec. Heat Temp. Service
"X" above the�work covered Ey this request. Enter remarks in this space and on the back of the white copy �nl .�
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a culate lnspectio Fee - This !ns i�on Request will not be accepied 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 ONLY T TAL�� �
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
I hereb cerfi fhaf 1 ins ted the electrical instalktion described herein on the dates sfated
Irriaation Boom v..,,..��., n.,b
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONT— H�
OFFlCE USE ONLY This requesf void 18 months from validaiion date printed in this box.
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PLEASE PRINT OR TYPE
Request ate Rough-in inspecfion required? ❑ Yes o Inspecfion Other Than Rough-In: ady Now ❑ Will Call
(You must call the inspecror when ready� Dafe Ready:
I, ' ensed contractor ❑ owner hereby re uest ins ction of the above electrical work at:
Jo6 Address (SMeef, Box, or Route No.) City Zip Code
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or No. � Range No. � Fire No.
Power Supplier Address
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Elecfrical Conhacfor �Compony Name)
o� oW�e�
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Phone No.
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�gnature �Contracto Owner rformin lation) ��� � r
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1 S/96 STATE D C Y- SEE INSTRUCTIONS ON BACK OF YELLOW
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