P - 835366�`9-��9 �
RE(�UEST FOR ELECTRICAL INSPECTION
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
" Commercial Industrial farm Remc
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 the white cop
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Calculate Inspection Fee - This Inspection Request will not be accepied wifhout the correct fee:
Other Fee # Service Entrance 'ze Fee # Circuits/Feeders
Mobile Home Park Stall � 0 to 00 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Ab e 200 Am s Above 100 Ai
Transformer/Generator INSPECTOR'S USE ONLY TOT,
Sign/Oudine Ltg. Xfmr. �
Alarm/Remote Conhol
Swimming Pool
I hereb certi thaf I ins fhe eleckical installation deuribed herein on the dah
Irrigation Boom �, ,� . RouAMn Dore
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Fee
�t�
Investigative Fee :G (�
THIS INSTALLATION MAY BE ORDERED DI$CONN D IF NOT COMPLETED WITHIN 18 MONTHS.
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.. OFFICE USE ONLY This request void 18 monfhs 6om validafion dafe printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspeclion required� ❑ Yes No Inspection Olher Than RougMn: ❑ Ready Now Will Call
�� (You musf call Ihe inspector when ready) Da�e Ready:
I, � licensed confractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �SRaet, Box, w Route No.) Ciy Zip Code
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or No. Range
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Phone No.
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Confractor License No. � Master Lic. No. (Plant ElecF. Only)
Mailing Address (Confracfor or Owner rming nsfallafion�
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A wi Signafure (Conhacfor or Own r Performing Insfallafion� Phone No.
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1 A-11 /96 STATE BOARD COPY - SEE INSTRUCiIONS ON BACK OF YELLOW COPY