P - 832376,FJ� 564 �
Commercial Industrial
RE(�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity "' �'
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800
Apt. Bldg. Other: New Addn
Farm Remod epcair
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above fhe work covered by�this reAuest. Enter remarks in this s ace and on ihe back of the white c�op only.
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Calculaie Inspection Fee - TF�is Inspection Request wi!! nof be accepfed 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 0 a
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps 4
Trnncfnrmcr�C�oncrnfnr INSPFCTOii'R IISE ONLV TOT.�L
,e �r9. xfm�.
iote Control
Pool
� Investigative Fee � �
THIS INSTALLATION MAY BE ORDERED
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herein on the dates stated
�--_ I Date �1 �G �
T—a�..—
IF NOT COMPLETED WITHIN 18 MONTHS.
. OFFICE USE ONLY This requesf void 1 B months from validation date prinfed in this box.
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PLEASE PRINT OR TYPE
Request Date r./ Rough-in inspecfion required$ ❑ Yes o Inspecfion Olher Than RougMn:
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�, �You must call }he inspecfor when ready) Dafe Ready
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Roufe No.) �" �
7330 �yRie L�ne �� rai���
Seclion No. Township Name or No. Ronae No. Fire No. CounN
Occupant
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Power Supplier
:al Conkocfor (Company Name)
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g Addres (Contracror or Owner Performing In:
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tF ture �Controcfor or O�yer Perfoy�
Now 0 Will Call
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I Phone No.
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hacfor License No. Master Lic. No.
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