P - 81811, � I'�' RE(1UEST FOR ELECTRICAL INSPECTION
8 0�= 2 5 8��,O innesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
, " Phone (612) 642-0800 `"fi°'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm emoc
Air Cond. Htg. Equip. Water Htr. Lood Mgmt. Other:
D er Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enier remarks in this space and on the back of the white copy
Calculate Inspection fee - This Inspection Request will rot be accepted without the correct f�e:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Tronsformer/Generator INSPECTOR'S USE ONLY TOTA �'J�
Sign/Oudine Ltg, Xfmr. �G.,�� '� �k�� � �•JV
Alarm/Remote Conhol 7,.,$'$�`�'
$Wimming POO� '�1 � hereb certi that I ins ed the elechical installotion described harein on the dates stated
Irrigation Boom RougMn Da�
Special Inspection � —(O � G �
Final
Investigative Fee ��2 7— °'Z
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITNIN 18 MONTHS_
OFFlCE USE ONLY This requesf void 18 months from validation date prinfed in this box.
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PLEASE PRINT OR TYPE ���0
Req�est Date � Rou h-in ins ection re uired? Yes
g p q ❑ No Inspection Other Than RougMln: ❑ Ready Now Will Call
� 7 v (You musf call the inspecfor when ready) Date Reody:
I, ❑ licensed contractor� owner hereby request inspection of the above electrical work at:
Job Addreu �Street, Bo or Route No.) Ci y Zip Code
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Phone No.
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Confractor License No.
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STATE BaARD COVY - SEEIINSTRUCTIONS ON BACK OF YELLOW COPY
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