P - 81235838-357 �
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Home Duplex
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electric+ty
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 ' �"' "�'
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Other: New ddn
Commercial Industria{ Farm Remod
Air Cond. Ht . Equip. Water Htr. Load Mgmt. Other:
Dryer Range E1ec. Heat Temp. Service
"X" bove �he work cove d b this requ st. Enter remarks in this space and on the bac of the white co y only.
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Calculate Inspection Fee - This inspection Request will not be accepted without ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps � 0 to 100 Amps
Street Ltg./Traffic $ig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA
Sign/Outline Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Pool
1 hereb certi Ihat I ins the eleclrical installafion described herein on 1he dates sMred
Irriqation Boom e,,,,..w� n..,o
Fee
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THIS INSTALLATION MAY BE ORDERED DIS�ONNECTED IF NOT COMPLETED WIrtHfPF18"MON'fHS.
OFFICE USE d7LY This raquest void 18 month om validation date printed in this box.
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PLEASE PRINT OR TYPE
9;B5f �0�� Rough-in inspection required8 Yes ❑ No Inspecfion Other Than Rough-In: ❑ Ready Now Will Call
� (You must call the inspector w n eady� Date Ready:
licensed contractor ❑ owner hereby request inspection of the above electrical work at:
� Address �Sheef, Box, or Ro4re No.) . . iy Zip Code
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cfion No. ownship Name or . Ranpe No. Fire No. CounN w _:
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Power Supplier
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Mailing Address �Con�actor or Owner
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u ' ed ' noture (Conhacfor oj O�
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A-11 8/96 STATE BOARD COPY - SEE
Phone No.
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Conhaclor License No. Masfer Lic. No.
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INSTRUCTIONS ON 6ACK OF YELLOW COPY