P - 83034REQUEST FOR ELECTRICAL INSPECTION �
6/� Q,�� Z�� � Minnesota State Board of Electricity
4 � 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �;
� Phone (612) 642-0800 "�'
ome Duplex Apt. Bldg. Other: New Addn
C mmercial 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 reque E�ter r marks in this space and on the back of the whiie copy only.
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Cakulate Inspection Fee - This Inspection Request will not be accepted withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Am s
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL/��
SignfOudine Ltg. Xfmr. �
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins the elechical installafion dasuibed herein on the dates statad
Irrigation Boom RoogMn Dare
Speciallnspect' '
Finol ° � �
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCO CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months 6om validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Request Da � Rough-in inspecfion requiredi ❑ Yes o Inspeclion O�er Than RougMn: eadv Now ❑ Will Call .
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Job Ac}drr�sj
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contractor ❑ owner hereby request inspection of the above electrical work at:
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- SEE INSTRUCTIONS ON BACK O� �LOW COPY