P - 8342853�-�43 �
Home Duplex
Commercial Industri
"X" above the work
REQUEST FOR ELECTRICAL INSPECTION =- �
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128 t. Paul, MN 55104
Phone (612) 642-0800 •� ��! .b �
l�'
Apt. Bldg. Other: �'/ /� New Addn
Farm ��LV'���,,� Uv� ?rflM Remod Reoair
� Elec. Heat � � Temp. Service �
request. Enter remarks in this space and on
copy
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to A � 0 to 100 Amps
Shee1 Lig.jTrafFic Sig. Above 200 Am s Above 100 Ai
Transformer/Generator INSPECTOR'S USE ONLY TOT,
line Ltg. Xfmr.
mote Conhol
� Pool
i
Boom
�he eleclrical inslollation described herein on the doles
Fee
�!' �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFRCE IISE OpLY This roquest void 18 months f�om validation date pfinaed in this box.
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I IIII I) II) II III II III I IU II III II IlI II III I III{ �!
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* � 5 3 2 5 4 3 [� �k PLEASE PRINT OR TYPE
Request Date � Rough-in inspecfion required$ Yes ❑ No Inspeciion Olher Than RougMn: ❑ Ready Now �II Call
Nb (f a� �$ (You must call the inspecror n ready) Dare Ready:
I, ❑ licensed conhacror 0 owner hereby request inspecfion of the above electrical work at:
�,�da� �s��. a�X. o. eo�,re rv�., c�a �' r' �// Z'� `� 4/ a!
�002� �i�-.��y �r' /`��
Seclion No. Township Nome a Nq,� Ran� . Fire No. Couny`�
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o��� rt� r�.
t�ei1� c��.d �n C2 �arl�Qr l�la ����-34��
Power Supplier Address r �
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Elechical Conkacror (Company Name) Conhaclor license No. Masler lic. �. (PIaM Elect. Only)
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Nloilirg Address �Conkacror w Owner Performing Installafion)
x�e No.
STATE BOARD COPY - SEE INSTRUC7WNS ON BACK OF YELLOW COPY