P - 83774.
���5-504 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
ome Duplex Apt. Bldg. Other: New
Commercial Industrial Farm Remoc
Air Cond. Htg. Equip. Water Htr. 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 white copy
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Calculate InsFection Fee - This Inspection Request will noi be accepted without the correci 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 Amps Above 100 Amps
Transformer/Generato� INSPECTOR'S USE ONLY TOTAL/j/'
Sign/Outline Ltg. Xfmr. p���C/. �?"5�17L/ �J' " `°'
Alarm/Remote Control /�//c._ s � - �/' /
Swimming Pool
I hereb certi fhaf I ins the elechical installation described herein on the dates stated
Irrigafion Boom r Rough-In � Date
Special Inspecti pa�e�
Investigative Fee � � / �'� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN MONTHS.
OFFICE USE ONLY This request void 18 monihs from validaficn dafe prinfed in ihis box.
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�K 0 5 2 5 5 � 4 7* PLEAS@ PRINT OR TYPE (
Requ ate �� Rough-in inspection required? ❑ Yes No Inspeciion Other Than Rough-In:� �; � dy Now Will Call
� �' �You must call the inspector when ready Date Ready:
i, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job A�� (Sh f, Box, r Route No.� �� � City � ,� Zip Code
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Secfion No. Township Name or No. R ge No. Fire No. Cou
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Occupant ,
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dress �Conkacf or Owner
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Phone No.
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Conha r Licens No�� Master Lia No. (Plant I
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BO R OPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY