P - 82930REQUEST FOR ELECTRICAL INSPECTION
6�("� /jQ Minnesota State Board of Electricity
V�`* � V � 1821 University Ave., Rm. S-128, St. Paul, MN 55104 =
� Phone (612) 642-0800
Home Duplex A t. 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 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 Inspecfion Request will nof be accepted withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreer Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT�� �
$ign/Outline Ltg. Xfmr. /
Alarm/Remote Control
Swimming Pooi
I here cerli ihaf I ins fhe elechical installation described�herein on the dates sfaied
Irriaation Boom p�Mi.,.. - n..m
Investigative Fee - -�f- 0
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTiiS.
�I� II��I ��I� OFFICE USE ONLY This request void 18 months from validation date prinfed in this box.
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Request Date
PLEASE PRINT OR TYPE
/ Rough-in inspecfion required2 ❑ Yes No Inspecfion Olher Than RougMn: Reody Now ❑ Will Call
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I, � licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address (Sheet, Box, or RouTe No.�
��y � � � Z;P �ode
Section No. 7owOnship Name o� , �� Range No. Fire No. r..��..w,
I Ocapant
�C"TY�C.. Ir�/� �qG� l�y� C
/itldress �Conhacfor or Owner Performina lo.�nll..ti...a -
30
Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY —��