P - 81904.
�.�c-265 �
Home Duplex
Commercial Industria
RE(#UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Apt. Bldg. Other: �,i New Addn
Farm Remod Reoair
Au Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. Service
"X" a ove the work covered,,b,� this request. Enter remarks in this space and on t back of the ite copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the corcect fee� �
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Sfall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Pool
Irriqation Boom
INSPECTOR'S USE ONLY
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I hereby certify that I inscected ihe electrical installation descrii
oare
Investigative Fee - �2�� ..,p '"".�'� ?-CZ
_THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN�$�AAONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion date prinfed in tliis box.
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�� PLEASE PRINT OR TYPE
Request Dale Rough-in inspecfion required$ ❑ Yes ❑ No Inspecfion Other Than Rough-In: ❑ Ready Now 0 W�II Call
�� 9'�'�� (You must call the inspector when ready� Date Ready:
I, ❑ licensed contractor�owner hereby request inspection of the above electrical work at:
i,.�, eaaro.. �cwm. w.,. .., v.,�� ni., � Citv Zip Code
Seclion No. � Township Name or No. � Range
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Power Supplier Address
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Electrical Conhaclor (Company Name� Con
Addreu (Contrador or Owner Performing Insl
:ed Signalure �Conh or or er Per ��
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b STATE BOARD
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ouny
Aivd�'r9�
Pho� No.
763 S7/-6 S�d',�
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- SEE INSTRUCTIONS OW BACK OF YEILOW COPY