P - 83575REQUEST FOR ELECTRICAL INSPECTION �
��n�' O n� � Minnesota State Board of Electricity
L L 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �;
Phone (612) 642-0800 `� '
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. 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 whiie copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correc► 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 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 ected fhe electrical insfallation described herein on the dates stated
Irrigation Boom Rough-In Dare
Speciallnspect' ' _
Final te
Investigative Fee _ ,z Z—
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request wid 18 months from validafion date printed in this box.
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PLEASE PRINT OR TYPE
Requ�Da�� � Rough-in inspection required$ ❑ Yes o Inspecfion Other Than Rough-In: eody Now � Will Call
G� (You musf call ihe inspecfor when ready� Dafe Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job A/dtIF treet, Box, or� /) � � Ciy Zip Code
/(/ [�J O ��/�G�'!� /�/ �t,°
Section No. Township Name or No. Range No. Fire No. Cou
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Occupanf Phone No.
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Power $upplier /� Address /�
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or ner Performing Install n)
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r Pe rming Installation� �,., Phone No //
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY