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Home Duplex
Commercial Industrial
Air Cond. Htg. Equi
Dryer Range
"X" above the work covered b
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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paal, MN 55104 `��
Phone (612) 642-0800✓'g �oq � � � `���
Apt. Bldg. Other: New Addn
Farm Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
>quest. Ent` 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 Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to �� 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amp:
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Lig. Xfmr.
Alarm/Remote Conkol
Swimming Pool
Irriqation Boom
that I ins the electrical installafion deuribed herein on the dates stated
Daie
Fee
.52� I
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONIY This request void 18 months from validation date prinfed in this box.
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PLEASE PRINT OR TYPE
Requegf Dat�� �� Rough-in inspection required2 ❑ Yes Inspeclion Other Than Roughan: ❑ Ready Now ill Call
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(You musf call the inspedor when ready) dale Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electricai work at:
Job Address (Sheet, Box, or Roule N � City • Zip Code
055 l� �i��-e S .N '� 55'4.�.
Section No. iownship Name or No. Range No. Fire No. Counry
Occupant
C°O 3�CLS � J
Power
al Conhacfor (Com y Nar
0.k�'e �
3 Address (Conhactor or i
S S J �►�a
ized $ignafure (Conhactor or
)1A-11 8/96 �
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Phone No.
15 H��-S71-O`f6�
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STATE BOAHD COPY - SEE INSTRUCTiONS ON BACK OF YELLOW COPY
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