P - 83574REQUEST FOR ELECTRICAL INSPECTION �
���3 6 9�1 Minnesota State Board of Electricity
V� 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �`;
r Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesl. Enier remarks in this space and on the back of the white copy only.
V`� _ V` � •
Calculpte Inspection Fee - This Inspection Requesi will not be accepted without the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the eleclrical installation described herein on the dates stated
Irrigation Boo Ro„9�i„ pa�
Special Insp
F,�� �� _ g
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DIS NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monifis (rom valid ion date printed in this box.�
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PLEASE PRINT OR TYPE
Reques ofe Rough-in inspecfion required2 ❑ Yes No Inspecfion Olhe� Than Rough-In: ea� Now ❑ Will Call
(You musf call fhe inspector when �eady) Date Ready: �
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
J h f Box, or�q �e No.) !�� '.� City Zip Code��
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Section No. Township Name or
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Power Suoo
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ddres (Conhacfor or Owner Performing
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sd S�nature �C�6n�racior or Owner Perfon _
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BOARQ COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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License
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Masffir Lic. No.
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