P - 81009REC�UEST FOR ELECTRICAL INSPECTION
O;L1 �-�. 5 7� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone (612) 642-08 0 ,�
Home Duplex Apt. Bidg. Other. I � ��°� New
Commercial Industrial Farm [ ' -%`� Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy
Calculate Inspection Fee - This Inspection Request will not be accepied without the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Tra{fic Sig. Above 200 Am s Above 100 Ai
Transformer/Generator INSPECTOR�S uSe ON�v TOT,
Sign/Outline Ltg. Xfmr.
AlarmJRemote Control ��.��i(�"�
� ",�,`+a
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Fee
� S�
Imestigative Fee 1�,� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date prinfed in this box.
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P�EASE PRINT OR TYPE
Requesf DafeO � � Rou h-in ins tion r uired? Yes .
� g pec eq ❑ No Inspecfion Ofher Than Rough-In: ❑ Ready Now Will Call
f �` �You must call the inspector when ready) ,. Date Ready:
I, ❑ licensed contractor [+�owner hereby request inspection of the above elecfrical work at:
1ob Address (Sheet, Boz, or Route No.) � Ciy Zip Code
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Occupanf
or
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Phone No.
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ny Name)
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or Owner PerForming Insfallation)
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:a �ignature �c,ontracror or Vwner Yertorming InsfallatiC � P
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A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY