P - 84169REQUEST FOR ELECTRICAL INSPECTION
� o� w� 7� Minnesota State Board of Electricity
� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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,. Phone (612) 642-0800 �
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod e air
Air Cond. Htg. Equip. Water Hh. 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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Calculate Inspection Fee - This Inspection Request will not be accepied without the correct fee:
Other Fee # Service Entrance $ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps � 0 to 100 Amps
Streef Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted ihe elechical insfallation described herein on ihe dates stated
Irrigation Bo RougMn Dare
Special Insp
Final �'
Investigative Fee � — � — �'
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validaticn date printed in fhis box.
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* O S O L 2� 6 O�K PLEASE PRINT OR TYPE o2`,)"�`t.J
Request Date Rough-in inspection required2 ❑ Yes
_ �❑ No Inspection Olher Than RougMn: Ready Now ❑ Will Call
(You must call the inspector when ready� Date Ready:
f, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or Route No.) Cify Zip Code
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Sect=on,No. I Township Name=r N_=^. � _° — I Range No.
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Power Supplier Address
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Ele�trical Contractor (Company Name)
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25$45
E INSTRUCTIONS C
Phone No.
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No. Master Lic. No. (Plant Elect. Only)
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