P - 83164REQUEST FOR ELECTRICAL INSPECTION
�� � � � � � � � 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 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 white copy only.
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Calculate Inspection Fee - This Inspeciion Request will not be accepted without the correc► fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Pork 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 TOTA�% �
Sign/Outline Ltg. Xfmr. f •
Alarm/Remote Control
Swimming Pool
I hereb certi that I inz fhe elecfrical installation described herein on the dafes sfated
Irrigation Boom _ eo�9l,ao Date
_ THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITFTIN 18_MON�iS _
OFFICE USE ONLY This request void 1 S months from validation date printed in this box.
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P ASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required2 ❑ Yes o Inspecfion Olher Than Rough-In: eady Now ❑ Will Call
� �You must mll the inspecror when ready) Date Ready:
I, ❑ censed contractor ❑ owner hereby request inspection of the above electrical work at:
Job ddress eef�, or Royt� No.) /� City �i�� Zip Code
7 �� �%'
Occupanf
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pr Owner
Phone No.
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Master Lic. No. IPlanf EIeM.
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COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY