P - 84247` REQUEST FOR ELECTRICAL INSPECTION
'�f�� J- 4 5 9 Minnesota State Boa�d of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
ome Duplex Apt. Bldg. Other: . New
Commercial Industrial Farm Remoc
Air Cond. tg. 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 Inspeciion 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 Amps Above 100 Amps
Transformer/Generator iNSPECTOR'S USE ONLY TOTAL�
�ign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi fhat I ins ted the electrical installafion described herein on the dates stated
Irri9ation Boom Rough-In Dare
Special Inspecti
Final DafQr2 /j-a
Investigative Fee — 6 �
THIS INSTALLATION MAY BE ORDERED DISC�DNNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months kom validation date printed in this box.
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* � 4 3 5 4 5 9 3* PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection required? ❑ Yes
���� n� ❑ No Inspection Other Than Rough-In: eady Now � Will Call
��� (You must call ihe inspector when ready) Dafe Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (St�ef, Box, or Route No.) City Zip Code
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Power Supplier
Electrical Con}ractor (Company
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Address
Confracfor License
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