P - 81562i�-936-�98
REQUEST FOR ELECTRICAL INSPECTION —
� Minnesota State Board of Electricity ?;
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us "�'
Commercial Industrial Farm od eF
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. Service
�.Y;' ab�work�d b is r�q�si. Efter f� r� n�s.pAce an on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Insfallafions Fee # Servic ance Size Fee Circuifs / Feeders Fee
Mobile Home Park Stall 0 t 20 mps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Abov Amps
Transformer/Generator INSPECTOR'S USE ONLY TO��� ,`
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Siqn / Outline Ltq. Xfmr.
herein on the dates smted:
Dafe
� Imestigative Fee I I� �� � �—z� � T1 'L--�'��"C�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MOATHS.
OFFICE USE ONLY This request void 18 monfhs from validation date printed in this box.
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PLEASE PRINT OR TYPE
Req�st at/ e, iTA Rough-in inspection requiredZ s ❑ No Inspection Olher Than Rough-In: ❑ Ready N ' I Cal)
i/( ���%,� You must call the inspector wh n ready Date Ready:
1, nse contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
I�h Addre reet, Box, o oute No.) Citv Zia Code
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No. Townshio Name or No. Rai
Occupa
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Power Supplier _ _ � Address
28 �
Name
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moanv or Owner Performi p
STATE BOARD COPY
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No.
0 3-��y-96c �
r License No. Moster Lic.
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SEE INSTRUCTIONS ON BACK OP YELLOW COPY