P - 82958REQUEST FOR ELECTRICAL WSPECTION
6���(� �� � Minnesota State Board of Electriciry
•7 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
ommercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this re est. Ent r remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This In iion Request will not be accepted wiihout the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator iNSPeCroR'S USE ONLY TOT, ,�
Sign/Oudine Ltg. Kfmr.
Alarm/Remote Coritrol �jl,,$7j
Swimming Pool
I hereb certi thot I ins the elecfricol installafion described herein on the dates smted
Irrigation Boom Rougl.ln Date
Special Inspectio
Final . J�eIC� v �
Investigative Fee J
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
. � OFFlCE USE ONLY This requesf void 18 monfhs from validafion dafe prinfed in this box.
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PLEASE PRINT OR TYPE
Requesf DaM�/ — � Rough-in inspecfion required? ❑ Yes o Inspecfion Ofher Than Rough-In: Ready Now 0 Will Call
t(� � (Yov must call ihe inspector when ready) Dafe Ready:
I, icensed contraclor ❑ owner hereby request inspection of the above electrical work at:
Job Ad�d ss Str r, Box, Route No.) � Ciry �/� Zip Code
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$ecfion No. Township Name or No. nge No. fire No. C nty /�/J /`K
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Occupant �� Phone No.
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Power ppli Address �
�r�a,� �'���'c /�60/ �.� l�'
Eleclric �(C m�t Na � �` Co acror Licg� �oS Master Lic. No. (Planf Elecl. Only)
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ilinp Address IContmcMr or Owne�Pedormina lnstallationl , // // i
�, Installation � / Pho No.
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COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY