P - 80689REQUEST FOR ELECTRICAL INSPECTION �
�� S�_ �� 8� � 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 e
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/Generotor INSPECTOR'S USE ONLV TOTA�,. ,r- ,,
line Ltg. Xfmr.
mote Control
� Poa�
Boom
�a.s�
on the dates stated
' Final Dafe
Investigative Fe � ) 2 — �--0�
THIS INSTALLATION MAY BE ORDEREU DISCO CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months 6om validafion dafe printed in this box,
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PLEASE PRINT OR TYPE
Request Da / ^ � Rou h-in ins tion r uired?
�� g pec eq ❑ Yes Inspection Other Than Rough-In: dy Now ❑ Will Call
�You must coll the inspector when ready) Date Ready:
I�icensed conhactor ❑ owner hereby request inspection of the above electrical work at:
1011 Address �Sheet,�Bo�c, or Roure No.� _ , ;� City�, i; Zip Code
Name or No. � — � Range No. � Fire No.
�i,
Phone No. � j
r J� I
Conhacfor �Company Name) �n � � � Confracfor License No. � � Master lic. No. �Planf Elect.
or
Signature �Conhactor or
1 ��— - ' J C J �� 1
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OP YELLOW COPY
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