P - 80751REQUEST FOR ELECTRICAL INSPECTION °'E
�� 1�- 2 0 2� 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 (ndustrial Farm Remod Re oir
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this rPquest. E�ter remarks in ihis space and on the back of the white copy only.
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Calculaie Inspechon Fee - This Inspection Requ�st w' not be accepted w+�hout th orrect 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 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT
SignJOudine Ltg. Xfmr. i
Alarm/Remote Control
Swimmin Pool
9 I hereb certi that I ins ted the elechical installation described herein on the dates sta�ed
Irrigation Boom Rouglfln Dare
$peciallnspe `
Finol
Investigative Fee -- Z
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WlTHIN 18 MONTH .
OFFICE USE ONLY This request void 18 months hom validation date printed in 11iis box.
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PLEASE PRINT OR T1lPE
Request Date � Rough-in inspecfion required$ ❑ Yes o Inspecfion Ofher Than Rough-In: Ready Now ❑��I Call
�j "' �(You must call fhe inspecfor when ready) Dafe Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at: ,
Job Ad ss treer, Box, u�e Ciry Zip Code
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Sedion No. Township Name or No. Range No. Fire No. Cou
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Occupanf ' Phone No.
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Power Supplier Address
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Elec a C h ct r(Co Name) Con acror License Master Lic. No. (Plant Ektit. Only)
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BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY