P - 832996,�3-454 �
Home Du
Commercial Ind
Air Cond. Htc
Dryer Rqi
"X" above the work cov�
=�r
REQUEST 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 Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
�is request. Enter remarks in this space and on the back of the white copy only.
�S7l��i�z �aa��i��
Calculate Inspection Fee - This Inspection Request will not be accepied 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 Ar
Transformer/Generotor INSPECTOR'S USE ONLY TOT�
Sign/Oudine Ltg. Xfmr. �
Alarm/Remote Confrol
Swimmin Pool
I here certi that I ins the eleclrical installafion described herein on the date
Irrigation Boom
Fee
��/
RougMn Dafe �/ _��
Specia) lnspection
Find
Investigati �— �
THIS INSTALLATI N MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHI 18 MONTHS.
OFF7CE USE ONLY This requesf void 18 months from validafion dafe prinfed in iliis box.
III�IIIIIIIIIIIIIIIIIIIIN�lilll�lll��I� • ��-���
* 0 6 6 3 4 5 4 7* ��,�0
PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspeclion required$ �Yes ❑ No Inspecfion Ofher Than Rough-In: ❑ Ready Now �W�II Call
/O .� 9 g� (You must call the inspector when �eady) Dafe Ready: .
I, �licensed conhactor ❑ owner hereby request inspection of the above elechical work at:
lob Address (Street, Box, or Rou�e No.) Ciy Zip Code
7 �9�7 ,(fia �y�.;. /_,.i �, �l�
or
�
No. I Fire No.
No.
� I
n A �
�e acrnr IComm .1 Conhactor License No. Masfer Lic.
ing Installafion) � Phone No.
26566 s�-�;
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY