P - 82968REQUEST FOR ELECTRICAL INSPECTION
5 J(r-� 6 7 3 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
. Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial tndustrial Farm Remod Re ir
Air Cond. Htg. Equip. Water Hfr. L�ad Mgmt. Other:
Dryer Ronge Elec. Heat Temp. Service
"X" obove the work covered by fhis request. Enter remarks in this space and on rhe bock of the white copy only.
' �� '_ " . A
Calcufate Inspection Fee - 7
Other
Mobile Home Park Stall
Street Ltg./Traffic Sig.
Transformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Poot
Irris�ation Boom .., ....
�specfion Request wiA r+ot be acce
Fee # Service Entrance Size
0 to 200 Amps
Above 200 Am
INSPECTOR'S USE ONLY
1 hereby certify that I
Rough-In
�hout the correct fee: y
Fee Circuits/Feeders
0 to 100 Amps
Above 100 Ai
Fee
�O
smled
Investigative Fee �
THIS lNSTALLATION MAY BE ORDEREQ DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� USE ONLY This request void 18 nths from wlidotion dote p�inted in this box.
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R�Sr �ore RLEASE PR1NT OR TYpE
�� f/a �� � Rougf�in inspecfion required8 ❑ Yes
�lJ (You must cnll the ins No Inspec�ion Ofher T{wn Rough.ln: ❑ Ready fNow �II Call
pecror when reorJy) �� R
�, �licensed contrector ❑ ��
owner hereby request inspection of the obove electrical w,o�k at.
hb Address �S7ee�, BoX� or Roure No.�
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STATE gpqRD COPY _ SEE INSTRI1CTInNg (� Recr nr
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