P - 82396REQUEST FOR ELECTRICAL INSPECTION
f, -�. 8 2�/� �� � Minnesota State Board of Electricity 3
U `t 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
,' (651) 642-0800 www.electricity.state.mn.us `'�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Hfg. Equip. Water Htr. Load Mgmt. t er:
Dryer Range Elec. Heat Temp. $ervice
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculote Inspec►ion Fee - This Inspection Request will not be accepted without ihe correct iee:
Other Installations fee # Service Entrance Size Fee # Circuits / Feeders Fce
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr. ll.Lc.l.l��.0� .� � A�
Alarm/Remote Control
Swimming Pool
I here certi that I ins ted the eleckical insfallation described herein on the dates sMkd:
Irrigation Bo Rough-In �a�
Special Insp
Final �
Investigative Fee �3 �CX'
THIS INSTALLATION MAY BE ORDERED DISC CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from va�idation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Date � Rough-in inspection required$ ❑ Yes o Inspection Ofher Than Rough-In: eady Now ❑ Will Call
:� �, ', ��fii � You must call fhe inspector when ready � Date Ready: �
1,�4censed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheef, Box, or Route No.� City Zip Code
I Secfion No. I Township Name or
Occupant
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ompany Name
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cror, Company or Owner Performing
acfor, Com ny o ner Pe rJ
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STATE BOARD COPY
Phone No.
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Confractor License No.
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Elect.
Phone Number I
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INSTRUCTIONS ON BACK OF YELLOW COPY