P - 80741. REQUEST FOR ELECTRICAL INSPECTION
R'L V- 2 0 5� 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 Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Fftr. 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 oniy.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correci fee:
Other Fee # Service Entrance Size Fee # CircuitsJFeeders Fee
obile 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 TO
Sign/Oudine Ltg. Xfmr. � �
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins the electrical installafion described herein on the dates stated
Irri9ation Boom RougMn Dare
Special Inspect
Final r�
Investigative Fee /l —
THIS INSTALLATION MAY BE ORDEREO DISCONNECTED IF NOT COMPLETED WITHtN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Date Rough-in inspecfion required? ❑ Yes ❑ No Inspection Other Than Roughan: ❑ Ready Now ❑ Will Call
lG (You musf call the inspector when ready) Data Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Shcet, Box, or Roufe No.) Ciy Zip Code
b a.LTf� � it � /J �
� ion No. Township Name or No. Range No. Fire No. Counly
�vd
Occupant, Phone No.
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pplier
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Conhactor (Company Name)
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�ddress �Contmcfor or Owner Pedorming
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' �aaNre (Contractor o� ner Pedorming Installation� •� � s "' I pl
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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Lic. No.
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