P - 79893676=134 �
REGIUEST FOR ELECTRICAL INSPECTION
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
Commercial Industrial Farm Remod
Air Cond. Htg. Equip. Water Hir. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entranc 'ze Fee # Cir its/Feeders
Mobile Home Park Stall 0 to 00 Amps 0 to 1 0 m
Street Ltg./Traffic Sig. Above 200 Am s Above:100 Ai
TransFormer/Generator INSPECTOR'S USE ONLY TOT
Sign/Outline Ltg. Xfmr. . (
copy
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Addn
Fee
Alarm/Remote Control 2 g 6 2 2
Swimming Pool
I hereb certi that I ins the electrical installation described herein on the dates stated
Irrigation Boom Ro�Mn Dare
$peciol Inspeciion
Investigative Fee Final ^ ,z��
THIS INSTALLATION MAY BE ORDERED DI ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months hom validation date printed in this box.
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PLEASE PRINT OR TYPE IG � 3
Re9ue �°te RougFrin inspecfion required2 ❑ Yes �No Inspecfion Other Than Rough-I�: ❑ Ready Now ill Call
O� (You musf call the inspecror when ready) Date Ready:
1, � licensed contracror ❑ owner hereby request inspection of the above electrical work at:
Job Ad u(Sheet, Box, or Route o.) Ciy Zip Code
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oc�oponr
Power Suc
or No. � Range
�cfor (Company Name
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s �Conhacfor or Owner
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Phone No.
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Phone No:
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STATE BOARD COPY - SEE {NSTRUCTIONS ON BACK OF YELLOW COPY
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