P - 84603REQUEST FOR ELECTRICAL INSPECTION
4`t-7 � 4 7 6 Minnesota State Board of Electricity
1821 Uni��ersity Ave., Rm. S-128, St. Paul, MN 55104
" Phone (612) 642-0800 ' �
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Wafer Hfr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entranc ize F # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps �
$treet Lig./Traffic Siq. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA 0�C
Sign/Oudine Ltg. Xfmr. �
Alarm/Remofe Control
Swimming Pool
I hereb certi that I ins fed the electrical installoKon dexribed herein on fhe dates stafed
Irrigation Boo RougMn Date
Special Inspec '
Final pa �
Investigative Fee ` ��Bc –2�—
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation date printed in ihis box.
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R uesf Date �� Rougffin inspecfion required? ❑ Yes o Inspecfion Olher Than Rough-In: dy Now ❑ Will Call
�You must call the inspector when ready� Dafe Ready:
i, �licensed confractor ❑ owner hereby request inspection of the above elechical work at:
Job Address �Sheet, Box, or Route No.) Ciry Zip Code
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Secfion No. Township Name or No. Range No. Fire No. CounCT�
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Power Supplier Address
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Elechica onhactor �Company ie) Conhar_for L ense No. Master Lic. No. �Plant Elecf. Only)
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A ress (Con a Owner Performing Inslallafion) �� ��
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Authorized Signafu (Con or or er Perfo ing Insfallafion) -• f: �!'.` ,j; Phone o.
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E&OOOOIA-1 1 8/96 �7ATE BOARD COPY - SEE INSTRUCiIONS ON BACK OF YELLOW COPY