P - 82549REQUEST FOR ELECTRICAL INSPECTION "�
U� 9 3 0- 5 6 0� Minnesota State Board of Electricity �� �
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ��-°�
� " � (651) 642-0800 www.electricity.state.mn.us `���
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Hfg. Equip. Water Htr. Load Mgmt. Ofher:
ryer 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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Calculafe Inspe
Other Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Tra nsformer/Generato r
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
IrriQation Boom
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Fee - This Inspection Request will not be accepted without the correct fe •
# Service Enirance Size Fee # Circuits / Feeders Fee
0 to 200 Amps � 0 tb�� tnps
Above 200 Amps Above 100 Amps , j
INSPECTOR'S USE ONLY TOTAL
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on the dafes stated:
Date
Special Inspection
Final Dat "�
Investigative Fee —�; �
THIS INSTALLATION MAY BE ORDERED DIS ED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in fhis box.
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"' PLEASE PRINT OR E
Request Date Rough-in inspection required? ❑ Yes ❑ No Inspection Ofher Than Rough-In: Ready Now ❑ Will Call
� �� You must call fhe inspecfor when ready Dafe Ready:
1, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) Zip Code
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Section No. Township Name or Na. Range No. .- oun
Occupant ��`� .
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Power Supplier Adi
Electric I Contractor / Comp y Name
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Mailing Address (Contrador, Company or Owner Performing Ins
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Authorized Signature �Contracfor, Company or Owner Performiry
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.B-00001A-12 5/1999 STATE BOARD COPY
Phone No.
License No.
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY