P - 84020REQUEST FOR ELECTRICAL INSPECTION
5��,� � Q � � Minnesota State Board of Electricity
��— � 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone 612 642-0800 �;
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Home Duplex Apt. Bldg. Other: New Addn I
Commercial Industrial Farm Remod _
Air Cond. Htg. Equip. Water Mtr. Load Mgmt. Oiher:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request Enter r marks in t's pace and on the back f the white cop;� o�ly.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance ' Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps � 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR°s uSe oN�v TOTAL -L''zl
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irrigation Boom
Special Inspec . �
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that I ins ted the elecfrical installafiort described herein on }he dates stated
Dafe
Investigative Fee ` , ',��� Q� — �
THIS INSTALLATION MAY BE OFiDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 1 S monihs from validation date prinfed in this box.
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* 0 5 2 2 4 8 1 L�K PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? ❑ Yes ,E] No Inspection Other Than Rough-In: ❑ Ready Now.B Will Call
���1/ /� i �You must call the inspecfor when ready� Date Ready: .
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I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Street, Box, or Route No.) Ciy Zip Code
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Section No. Township Name or No. Range No. Firc No. County
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Occupant
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Power Suoolier i
Electrical Contractor (Company Name�
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Mailing Address �Confraclor or Owner Performing Insfallafio
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or
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Phone No.
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Phone No.
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