P - 84664468-234
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Home Duplex
REQUEST FOR ELECTRICAL INSPECTION -
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
. Other: New Addn
Commercial Indushial Farm
Air Cond. Htg. Equip. �'' Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enier remarks in this space and on ihe back of the
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Cakulaie Inspeciion Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/I
Remod
copy
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amp:
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Oudine Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
i
I hereb ceAi that I ins �he elecfrical installafion dexribed herein on the dates sn
Irrigation Boom eo�Mo p�
Fee
Imestigative Fee " _ k� �_ Z _, C'�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED iF NOT COMPLtTED WITHIN 18 ONTHS.
OFFICE USE ONLY 1}�is requesf void 18 months (rom validaHon date printed in this box.
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Req sf Date Rough-in inspection required? ❑ Yes No Inspecfion Other Than RougMn: Ready Now ❑ Will Call
� .�' % �You must call the inspector when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above e�ecfrical work at:
Job Address (Sheef, Bo or Route No.� City � ZiP C�
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Secfion No. Townsh p Name or No. Ranpe No. Fire No. CounN
Occupant �
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Phone No.
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Yical Conhacfor (Company Name) � Conkacfor License No. Masfer Lic. No. �Plant Elecf.
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ing Address (Conhacfor or Owner Performing Insfall on
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oriz g re (Co rmirg Insta n� - Phone No.
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�00 �96 ATE BOARD COPY - SEE INSTRUCTiONS ON BACK OF YELLOW COPY