P - 80976REQUEST FOR ELECTRICAL INSPECTION
� O�- 517 � Minnesota State Board of Electricity
„ 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �`
Phone (612) 642-0 0
;Home Duplex Apt. Bldg. Other: � New Addn
Commercial Industrial Farm Remod Re ir
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" pbove the work covered by this request. Enter remarks in ihis space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Requesf wifl not 6e accepted without the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeder Fee
Mobile Home Park Stall 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 Control
Swimming Pool
I hereb certi that I ins the elecfrical installation described herein on the dates stated
lrrigation Boom Rough-tn pate
Special Inspecfio
Final � Da � . ` .
Investigative Fee �+
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED W IN 1 MONT .
OFFICE USE ONLY This request void 18 monlhs irom validafion dafe prinfed in this box.
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PLEASE PRINT OR TYPE
Requesf Date Rough-in inspecNon required$ ❑ Yes ❑ No Inspection Other Than RougMn: eody Now � Will Call .
,/+' ��..� (You musi rnll fhe inspector when ready) Dafe Reody: �
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Add�trcs (Sheet, Box, or Route No.� Ciry �� Zip Code
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Se tio o. ownship Name or No. Range No. Fire No. Co ty
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'� Phone No.
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Sor (Co pany Nam ` Conhncfor License No. _ Masfer Lic. No. �Plont Eled. Only)
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(Conhactor or er Performing Installation� � � � �� ^
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ture (Conh kr r Owrier Pe ormi�g InsTallation) � Phone No.
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96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY