P - 80757REQUEST FOR ELECTRICAL INSPECTION
Q�.Q � Q� Q � Minnesota State Board of Electricity
V �J V V 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone(612)642-0800 " �
Commercial I I Industrial
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Calculafe Inspection Fee - This Inspe
Other Fee
Mobile Home Park Stall
Street Ltg./Traffic Sig.
Tra nsformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
1_:__a'__ D___��.'_ -
farm
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in tl�is space and on tl�e back of tt
% (��% e%� C�
:tio R uest will not be accepied without the correct fee:
# Service Entrance Size Fee # Circuifs
0 to 200 Amps 0 to 100 A
Above 200 Am s Above 100
INSPECTOR'S USE ONLY
New
Remod
ite copy
Fee
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I hereb certi that I ins ted the elecfrical insmllafion described herein on the dates stafed
RouaMn DaTe
Investigative Fee � e---✓ — Z --�p�j
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
. OFFICE USE ONLY This request void 18 months from validafion dafe prinTed in this box.
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* 0 8 3$ 8 2 8 2* ��a 7
PLEASE PRINT OR TYP
R�1 Da� -�� Rough-in inspection required? ❑ Yes ❑ No Inspection Other Than RougMn: Ready Now ❑�II Call
�You must call the inspector when ready� Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job ddress (Sfreet, Box, or Roufe o.� Ci /� Zip Code
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Section No. Township Name or No. Range No. fire No. Coun ���
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IC. ING.
Phone No.
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License No.
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COPY - SEE INSTRUCTIONS ON BACK OF YELLOW
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