P - 80099RE(�UEST FOR ELECTRICAL INSPECTION � �
�/) � � � � �1 � Minnesota State Board of Electricity
'� 1 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�overed by this request., Enter remarks in this spaece C� on the ck of the white copy only.
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Calculate Insp�ction Fee This Inspection Request will noi be accepied without the correcF fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Tra�fic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S usE oN�v TOTAI, v� �n
iote Control
Pool
on the dares seowed
� Investigative Fee j � �/� /l� v�--
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monlhs fran volidafion daTe prinfed in this box.
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PLEASE PRINT OR TYPE
Request Dote ^�„ �y. Rough-in inspecfion required? Yes ❑ No Inspecfion Olher Than RougMn: ❑ Ready Now ill Call
� Q�as ��V ou must call fhe inspecfor when ready� Dale Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addreu (Sheet, Box, or Route No.� City Zip�
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Seclion No. Township Name or No. ange No. Fire No. Co
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Occupanf � ` � � ' f _ Phone No.,
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Power
Elechicnl Conhacror Com �Name Contractor License No. Masrer lic. No.
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Mailing ress (Contrador or Owner Performug Insfall tion)
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- SEE INSTRUCTIONS ON BACK OF YELLOW COPY