P - 83494REQUEST FOR ELECTRICAL INSPECTION
6��' 3 0 4 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 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
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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
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Ai
Transformer/Generator INSPECTOR'S USE ONLY T
Sign/Outline Lig. Xfmr. �
Alarm/Remote Control
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Fee
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Swimming Pool I hereb certi that I ins ected the elechical installation described herein on the dates stated
Irrigation Boom Rough�ln DO�e �_2d �
Special Ins t �� ' f° p G
,- Final � . — Z /`
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY 14iis requesf void 18 months from validafion daTe prinfed in this box.
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PLEASE PRINT OR TYPE
Request ate Rough-in inspeclion required2 es ❑ No Inspection Other Than Rough-In: ❑ Ready Now
7 13/� Q �You must call tf�e inspector when ready� Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above elechical work at:
lob Address (Sheef, Box, or Route No.� City Zip Code
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Secfion No. Township Name or No. anpe No. Fire No. CounN
Occupanf
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Power Su[
il Confracfor (Company Name)
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Address (Contmctor or Owner Perfo
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ied Signature C' fractor or Owner I
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Phone No.
Call
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License No. MasTer Lic. No. (Plant Elecf. Only)
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