P - 82372U-�5�2�3�9 �
Duplex
Indusfrial
REQUEST FOR ELECTRTCAL INSPECTION
Minnesota State Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55704-2993 -
(651) 642-0800 www.electricity.state.mn.us "'
Apt. Bldg. Other. New Addn
Farm Remod Repair
Air Conditioner Htg. Equip. Water Hir. Load Mgmt. Other: I
Dryer Range Elec. Heat Temp. Service
"X" above the wor covered by this request. Enter remarks in this space and on the back of the whi►e copy only.
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Calculaie lnspeciion Fee - This Inspection Request will not be accepted withouf fhe correct fee:
Otherinstallations Fee # ic nce Si e Fee Circuiis / Feeders '�L
Mobile Home Park Stall 0 t 200 mp 0 to 100 Amps
Street Ltg. / Traffic Sig. Ab 0 Amps Above 100 Amps
Transformer/Generptor INSPECTOR'S USE ONLY �.� TO L
Sign / Outline Ltg. Xfmr.
Alarm/Remote Contro,l �D.S Q
Swimming Pool
I hereb certi fhat I ins cfed the elechical installation deuribed he�ein on fhe dotes sfafed:
Irrigation Boo Rough-In Da�e - _
Special Insp
Final te
Investigative Fee p — Q � ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT CO LETED WITHIN 8 MONTHS.
OFFICE USE ONLY This requesf id 18 monfhs r val�n date printed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Da � � Rough-in inspecfion required2 ❑ Yes ❑ No Inspecfion Other Than Rough-In: ❑ Ready Now ❑ Will Call
� 6 You musf call the inspecfor when ready Date Ready:
1, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job A�s �Sfreef, Box, or ute No.) ��� �� Cit�� _-� � � Zip Code
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Secfion No. Township Name or No. � Range No. Fire No. Coun �
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1999 STATE B ARD COPY
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License No. Master Lic. No. (Pla�f Elect. Only)
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY