P - 84735REQUEST FOR ELECTRICAL INSPECTION
4. � 1- 7 2 6 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
mercial Indusfrial Farm Remod
Air Cond. Htg. Equip. Water Hh. 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 ihe whiFe copy
Calculote Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR•s use ON�r � TOTAL
Sign/Outline Ltg. Xfmr. ��' G�� V �,�
Alarm/Remote Control . ��' Su
Swimming Pool
I hereb certi that I ins the elechical installation described herein on the dates stated
Irriqation Boom o��.�.,,, �_�
Invesfigafive F� V �i/ � ��"'� �� �"
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 ONTHS.
OFFICE USE ONLY This requesl wid 18 monfhs from validation date printed in this box.
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* � 4 9 7 7 2 6 0* PL SE PRINT OR TYPE �� �G�'t` I
Requesf J�� —7 Rough-in inspecfion required? ❑ Yes o Inspeclion Ofher Than RougMn: Ready Now ❑ Will Call
/ �`(ou must call fhe inspecfor when ready) Date Reody:
I, icensed conhactor ❑ owner hereby request inspection of the above elechical work at:
J Add u(Strcet, Bo , or Route No.) Ciy Zi Code
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Seclion No. Township Name or No. Ranpe No. Fire No. ounN / i
Occupant
Power up o
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or_Owner Pe
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Phone No.
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Con clor License N /
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STA7E BOA COPY - SEE INSTRUC'iIONS ON BACK OF ve��ow cnov
C? %�� , ��[=
Lic. No. (Plont Elecf. Oi
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