P - 82255$,Cz-20� �
REQUEST FOR ELECTRICAL INSPECTION °"
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �`
Phone (612) 642�800r, `�'
mmercial Industrial Farm �'- 5v �` Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL�%�
Sign/Outline Ltg. Xfmr. "T/• ��
Alarm/Remote Conhol
Swimming Pool
I hereb certi �at I ins the eleclrical installation described herein on the dates stated
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Speciallns o
Final Da
Investigative Fee _ Z— �-�Q
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request wid 18 months from validation dafe printed in this box.
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PLEASE PRINT OR TYPE
Request �1 Rough-in inspection required$ Yes ❑ No Inspection Other Than Rough-In: Ready Now 0 Wil) Call
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�/ �V(/ (You must call fhe inspecfw when ready) Date Ready:
�, ❑ licensed contractor�owner hereby request inspection of the above electrical work at:
Job Address (Slreet, Box, or oute No.� City Zip Code
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Secfion No. Township Name or o. Range No. Fire No. County
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Occupa � � j � Pho�e No.
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Power S plier
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Elechi�o�hacror (Cpmpany Name� /� _
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'� Contracfor License No.
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1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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