P - 811278��7-859 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-528, St. Paul, MN 55104
Phone(612)642-0800
ac�r
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod
Air Cond. Htg. Equip. Water Htr, Load Mgm . Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. fn►er remarks in �his space and on the back of the white copy only
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Calcufate Inspection Fee - This Inspe�equest wi not e accepted without ihe correc� fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps $ 0� ' 0 ro 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY "�" TOTAL
Sign/Outline Ltq. Xfmr. `�'-�'t'�"% •.S� .t��` '
Fee
Swimming Pool
I hereb certi that I ins the elechical inatallation described herein on Ihe dates stafed
Irrigation Boom Rough-In Dare
Special Inspectio
Investigative Fee . �� �—`— "-Z—�G
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE l�E ONLY This request void 18 months from validafion date prinfed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required? ❑ Yez �lo Inspeciion Olher Than RougMn: �eady Now � Will Call
��� '� '(� q (You must mll the inspeclw when ready� DaM Ready:
I, ,�censed contractor ❑ owner hereby request inspection of the above elechical work at:
Job Address (Sheer, Box, or Route No.� Ciy Zip Code
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Section No. Township Name or No. o. FecN� ouny
Occupant
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or Owner Performing Insfallafion)
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY