P - 81239��J-663 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
IC Home Duplex Apt. Bidg. �
Commercial Industrial Farm
New
Remod
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l�g -1£
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Air Cond. Htg. Equip. Water Hh. load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter re arks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Requesi will not be accep►ed wifhout 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 Am s Above 100 Amps
Transformer/Generator INSPECTOR•s use or►�r TOTAL� �
Sign/Outline Ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool
I hereb ceAi that I ins elechical inslallation described herein on the dares stated
Irrigation Boom RougMn Dafe � V�¢
Special Inspectio � �
investigative Fee
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THIS INSTALLATION MAY BE ORDERED DiSCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
�-- _ _ _------- —
OFFlCE USE ONLY This roquest void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request D�� R h-in ins ion uired? ❑ Yes
���� oug peM' req ❑ No Inspect:on Other Than RougMn: ❑ Ready No ill Call
�,/ �You musi wll the inspector when ready� Date Ready:
I, �licensed confractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (S� t, Box, yr Poute No/�� Ci� � Zip Code
%V'lf�C�• � 7�.% � !`—I
Section o. Township Name or No. Range No. Fire No. Cou�
� Occupanf ..
�nhactor� _ (Canpany Na e � )
l
Ti.{�� �
ress IConhacta� or Ownec Performina In:
or
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STATE BOARD COPY -
Phone No.
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i�r
1
ON BACK OF YELLOW COPY
No.