P - 82714REQUEST FOR ELECTRICAL INSPECTION �
51$ � V�� Minnesota State Board of Electricity
1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104 �
` Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re ir
Air Co Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this req� est. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will noi be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 ro 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer�Generator INSPECTOH�S USE ONLY TOT �O
SignjOudine Ltg. Xfmr. ^
Alarm/Remote Control
Swimming Pool
I h certi thaf 1 in the eledriwl installation dexribed herein on the dares sloea�i
Irrigation Boom Ro�gMn Dare
Speciallnspectio _
Fiml D
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WIT 18 MO S.
OFFN:E t�E ONLY This requestvoid 18 monfhs from validation dafe printed in this box.
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* � 5 l+ 8 8 6 2 8�Ic PLEASE PRINT OR TYPE �
Request Date Rough-in inspection requi�ed$ ❑ Yes Na Inspecfion Olher Than RougMn: Now ❑ Will Coll
2�5 —! 8 �`(ou must call the inspeclor when ready) Dafe Ready: ��
I, '� licensed contracror ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.) Ciy� � Zip Code
2 (� % l
.
Section No. Township Name or No. Range No. Fire No. Cou ly � .
Phwre No.
Lic. No.
�ContracMr w
aignature �c.ontrac�or or er Yertor " nsf afion 5 9� 1 P
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11 8/96 STATE BOARD COPY - SEE INSTRUCT10N3 ON BACK OF YELLOW COPY