P - 83030��8-863 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 .. _ �j�,;—�'j,
Commercial Industrial Farm �="'"'� C° Remod Re
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range 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.
Dig & wire trench to garage approx. 30'. Install dis-
connect switch, 2- GFI's, 2- fixtures, receptacle for
door opener, motion detector & switch.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps O to 100 Amps , p
$treet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator iNSPECTOR'S US� oN�v TOTAL
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
. I herebvi certi(v tha/ I
'� �
the elechiwl installaHon described herein on 1he dates stated
Dafe
� Investigative Fee � L � �"^G/ / jJ
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
.. OPFICE USE ONIY This requesf wid 18 months from validafion da�e printed in fhis box.
i��iiii�riiiriiiiii�ii�i�iii�ii�mi� . �s.s�
* D 6 4 8 8 6 3 9* �J��d
LEASE PRINT OR TYPE
R u t Dafe Rough-in inspection required? ❑ Yes No Inspection Other Than RougMn: ❑ Ready No Will Call
� (You musf call the inspecfor when read Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electricol work at:
Job Address (Street, Box, oyi2fldfe No.). /� / � City � Zip Code
ump rvame or rvo�/ I rcange rv<
/ /
Address
p (Com Nam ,
onhactor or ner Pe rming Installalion)
� i
i.
�e (Conhacfo o Owner Per ming I sfal i n)
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6 STATE BOARD COPY - SEE IP
No.
ON BACK OF YELLOW COPY
Lic. No.
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