P - 82011< REQUEST FOR ELECTRICAL INSPECTION
8 V L� 2 6 9� 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 Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt, Other:
D er Ran e Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Caicu►ate Inspection Fee - This Inspection Request will noi be accepied without ►he correcf fee: `
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stail 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
TranSFo�mer�Generator INSPECTOR'S USE ONLY � T�
Sign/Oudine Ltg. Xhnr. �' �e �
Alarm/Remote Conhol
Swimming Pool
I hereb certi thaf I ins the elechical installation described herein on the dates stated
Irrigation Boom Rou Mn Date
Special Inspection g �'8`' � � ��/
Investigative Fee F�nal Da� .�2„at
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validafion dafe priMed in lhis box.
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LEASE PRINT OR TYPE
Request Date Rough-in inspection requiredZ ❑ Yes No Inspection Ofher Than Rough-In: ❑ Ready Now Will Call
�You musf call fhe inspecfor when ready) Date Ready:
I, ❑ licensed contractor � owner hereby request inspection of the above electrical work at:
Job Addreu �Street Box, r Rou1e No.) Cify Zip Code
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Section No. Township Name o o. Ranpe No. Fira o. ouny
Occupant
No.
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Master lic. No.
11 8/96 /�ATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
s
No.