P - 83645REQUEST FOR ELECTRICAL INSPECTION �
't ��- 4 8 6 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:
Dryer Range Elec. Heat Temp. Service
"X" above the work covgred bZ this request. Enter remafks in this space and on the back of the white copy only.
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Calculaie Inspecfion Fee - This Inspection Requesf will not be accepied without the correct fee:
Other Fee # Service Entra�ce Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps • 0 to 100 Amps
$treet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL `
Sign/Outline Ltg. Xfmr. 3(�j , J�
Alarm/Remote Control
Swimming Pool
I hereb certi ihat I ins ted the electrical installaKon dexribed herein on the dates stated
Irrigation Boom Rough-In pa�
Special Inspectio
Finol
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MO S.
� OFFICE USE ONLY This requesf void 18 monihs from validafion dafe prinfed in ihis box.
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Requesf D e�� Rou h-in ins ection re uired? Yes
C 9 P q ❑ No Inspection Other Than RougMn: ❑ Ready No Will Call
Q �You must call fhe inspecfor when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of fhe above electrical work at:
lob Address (Sheet, Box, or Route No.) Ciy Zip Code
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No. I Township Naml,pf No. Range No.
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Address �Conhactor or Owner Pe orming Insl
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ed Signafure �nhacfor or Owner Pe rminc
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Phone No.
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Conhaclor License No.
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STATE BOARD COPY - SEE INSTRUCTIONS
Masrer Lic. No.
'hone No.
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