P - 83800��3�-201 �
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
Commercial Industrial Farm Remod
Air CondC� Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter emarks in this space and on the back of the white
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Calculafe Inspection Fee - This Inspection Request will not be accepted withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeder.
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic $ig. Above 200 Am s Above 100 A
Transformer/Generator INSPECTOR'S USE ONLY TO7
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins cted the electrical installation described herein on the dates stated
Irripation Boom Q�,,,,�,i„ pare
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copy only.
Fee
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THIS INSTALLATION MAY E ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion daie printed in fhis box.
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PLEASE PRINT OR TYPE
�u t Date � Rou h-in ins ection re uired? ❑ Yes
� ���/' �7 g p q ❑ No Inspection Other Than RougMn: eady Now ❑ Will Call
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I, �icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Jo���s�s �Sfreef, Box, or Roufe No.) ` Ci ^-� _ n
or No. � Range No. � Fire No.
Ma7ng Address �Conhacfor or Owner
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Authorized Signature (Coynae�oror O�
Phone No.
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Conhacfor License No. Master Lic. No. �Planf Elecf. Only)
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Phone No.
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