P - 80629,� REQUEST FOR ELECTRICAL INSPECTION
.� � J- 9 3 2 � Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
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 request. Enter remarks in thi space and on the back of the white copy only.
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Calculate Inspecfion Fee - This Inspection Requesf will not be accepted without the correct fee:
Other Fee # Service Entrance Size fee # Circuits/Feeders Fee
Mobile Home Park 5tall O to 200 Amps 0 to 100 Amps
Street Lig./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Oudine Lfg. Xfinr.
Alarm/Remote Confrol
Swimming Pool
I hereb certi that I ins ted �he elechical installafion described herein on the dates sfated
Irrigation Boom RoogMn Dare
Special lnspectio
final ��
Investigotive Fee 3
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED W 18 MONT .
OFFlCE USE ONLY This requesf void 18 months (rom validafion dafe printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe �Rou h-in ins on r uired2 Yes o Ins
�y ('� 9 P��� eq ❑ pection Od+er Tlwn RovgMn: ❑ Ready Now ' I Ca11
��%�� (You must call fhe inspecfor when ready� Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above elechical work at:
lob Address (Sheet, Box, or Route No.) Ciy Zi C e
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Seclion No. Township Name or No. Range No. Fire No. Couny _
Occupanf Phone No.
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crnmoCOr
A;C EL.ECT., iNC
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Conhactor
M�ure �C.on r o ner Pertormipp Installafion� t,Z �] � I Ph�e No.
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8/96 y .�� ���RY.� SEE lNS7RWCTIONS ON BACK OF YELLOW COPY