P - 82764'' RE(�UEST FOR ELECTRICAL INSPECTION
C� Pj ��(� C m Minnesota State Board of Electricity
J L lJ U 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �`;
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
ommercial Industrial Farm Remod Re air
Air Co Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calcul'ate Inspeciion Fee - This Inspection Request will not accepfed without ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL .�' l
Sign/Outline Ltg. Xfmr. v
Alarm/Remote Conhol
Irrigation Boom Ro„9�„ pa�
Special Inspe ' °
g . e��ai oa�Z-3 —P.2'%
Investi ative Fee
THIS INSTALLATION MAY;BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months 6om validation date printed in this box.
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* 0 6 7 2 2 0 6 0* ��57
PLEASE PRINT OR TYPE
�°� Rougffin inspeclion required$ ❑ Yes ❑ No Inspection Other Than Rough-In
��/' q� (You must call the inspec�w when ready) Dafe Ready: /
licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Iress (Sfreet, Box, or Roufe No, City
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No. Township Name or No. Range No. Fire No. County �
� Occupanf
Ready Now ❑ Will Call
Phone No. -/
✓ Y ��„ �
7
Address
Contracfor License No. Moster Lic. No. (Plan
IC. INC. � ��-
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Signature (Conkactor or Own rforming Insfallafion� - Phone No.
sO90
�� 8� STATE BOA Y- SEE INSTRUCTIONS ON BACK OF YELLOW COP "�