P - 81087REQUEST FOR ELECTRICAL INSPECTION °'E
-�` O�� O�i /1 � Minnesota State Board of Electriciry
U O G�t 1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104
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Phone(612)642-0800
ome Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Lood Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in fhis space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspe
Other Fee
Mobite Home Park Stalt
Sheet Ltg./Traffic Sig.
Tra nsformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimminq Pool
�n Request wi(1 not be acc�
# Service Entrance Size
0 to 200 Amps
Above 200 Am
INSPECTOR'S USE ONLY
wit{�ouf ffie correct fee:
Fee # Circuits/Feeders
0 to 100 Amps
Above 100 Ar
Fee
Investigotive Fee ` i .�n � Z--�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. _
OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinfed in ihis box.
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PLEASE PRINT OR TYPE V�50
RequesY Date Rough-in inspection required2 Yes ❑ No Inspecfion Other Thon RougMn: ❑ Ready No ill Call
/ � � (You musf call the inspactor when ready) Date Ready:
I, �licensed confracror ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Sheet, Box, or Roufe No.) , City � Zip Code
No. � Township Klame o� No. � Range No. � Fire No.
Occupant
Power
Phone No.
Conhacror License No.
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COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
Lic.
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