P - 80986REQUEST FOR ELECTRICAL INSPECTION
Q�,? ���� � Minnesota State Board of Electricity
V `� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone(612) 642-0800 " '
ome Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod X Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
D er Range Elec. Heat Temp. Service
"X" a6ove the work covered by ihis request. Enter remarks irt this space and on ►he back of the white copy only.
� U�7ERIDE� � 2.'� 6q 7� ���I�RC� tZ.�p(�'t.Cevhevrt.
Colculate Inspection Fee - This Inspection Request will not be accepted wi►hout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park $tall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. `� �•�
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins cted the elechical installafion described herein on the dates slafed
Irrigafion Boom Rough-In ,_. Dare
Special Inspectif' t �; „ , "
' Final " � � , Da
Investigative Fe � �.. Z �'e_ OZ
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs 6om validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Request Date Rou h-in ins eclion r uired? ��f�l pecfi g dy ❑ Will Call
/ g p eq ❑ Yes o Ins on 01her Than Rou h-In: �ea Now
`O/'%�,�� �You must call the inspecfor when ready� Date Ready:
!,'�Censed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address (Sheet Box, or Route No.) � CiN Zip Code
R N NF �Ri DL�Y
Township Name or No. Range No. Fire No. Counfy
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW