P - 82338' _�„ �EST FOR' ELECTRICAL �NSPECTION
�� ��y (� �-� C 3 I�I nnesota State Board of Electricity
l: J J�. J �� �821 University Avenue Suite S•128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.e%ctricity.state.mn.us
Home Duplex Apt. Bldg. Other: New
Commercial Industrial Farm Remc
Air Conditioner 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
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copy only.
Calculate Inspec►ion Fee - This Inspection Request will not be occepted without the correct fee:
Other Installafions Fee # Service Enhance 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
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
_ , I herebvi certi(y that I inspecfed the elechical
Date
Investigative Fee_ F���� C� �---� �� . Z.�^ G
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY is requesf void 18 months from validafion date printed in fhis box.
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PLEASE PRINT OR TYPE
Request Dafe Rough-in inspecfion required8 ❑ Yes o Inspecfion Other Than Rough-In: � eady Now � Will Call
You musf call fhe inspecfor when ready Date Ready:
1, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Street, Box, or Route No.) Ciy Zip Code
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Section No. Townshio Name or No. Ranqe No. Fire No. Coun �
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Compa�y Name
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or Owner Performing Insfallafion�
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2 5/1999 STATE BOARD COPY
Phone No.
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Coohactor License No. Master Lic. No. (Plaat Elect. Only�
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Phone Number
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY