P - 83119REGIUEST FOR ELECTRICAL INSPECTION �
6;�. �' 4 7 5 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �:
'r` Phone (612) 642-0800
ome Duplex Apt. Bldg. Other: New Addn
ommercial Industrial Farm Remod Re ir
Air Co . Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Ran e Elec. Heat Temp. Service
"X" above the work covered by this reques►. EnFer remarks in this space and on the hack of the white copy only.
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'culaCyYns�pection Fee - This Inspecti
Other Fee
Mobile Home Park Stoll
Street Ltg./Traffic Sig.
Tronsformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I
Irriqation Boom
on Request will not be accepted without the correct fee:
# Service Enhance Size Fee # Circuits/Feeders
0 to 200 Amps 0 to 100 Amps
Above 200 Am s Above 100 Amps
INSPECTOR'S USE ONLY TOTA�r �
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that I inspecled the elechical installation dexribed herein on the dales slated
Dare
nner � vare O�
Investigative 3 �
CHIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from volidation dofe prinfed in ihis box.
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Occupant
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PLEASE PRINT OR TYPE
a g� Rough-in inspeclion required? ❑ Yes ❑ No Inspection Other Than RougMn: Ready Now ❑ Will Call
(You musf call the inspector when ready) DaM Ready:
>ed confractor ❑ owner hereby request inspection of the above electrical work aT:
�heet, Box, or Rovle No.) Cily Zip Code
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Township Name or No. Ranqe No. Fire No. Cou .
er
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Coon Rapids Bivd. N
�Phone No.
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C ha or License No. Master Lic. No. �Plant Elec1. Only)
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or Owner Performing s Ilafion� Phone No.
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ST BOA D COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY �