P - 83105REQUEST FOR ELECTRICAL INSPECTION ���..
5 3 2��,r'aJ •!. - Minnesota State Board of Electriciry
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: ' w Addn
Commercial Indushial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other: �
Dryer Range Elec. Neat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 3 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Geoerator INSPECTOR'S use ON�r ',�� TOT 1
Sign/Oudine Ltg. Xfmr. �� 'r ( /
Alarm/Remote Control �j � 0 4 �
Swimming Pool �� � �--�
I here certi that I'ios the electricol inslallafion described heiein on the a�es s
�ff79OflOf1 BOOfiI Rough-In .
SpECIO� �FlS�CtlOfl � � �
pec �
Investigative Fee �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFCE USE WlLY This requesf void 1.8 months from validafion date prinped i� this box.
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* 0 5 3 2 4 9 1 8�K PLEAS� �r�e
Request Date � Rough.in inspeclion requiredi ❑ Yes ❑ No Inspection Olher Thon RougMn: ❑ Reody Now ❑ Will Call
�You must call the inzpector when ready) Da�e Ready:
I, ❑ licensed contractor owner hereby request inspecfion of the obove elech�a� work at:
J Add� (Sheet.'Box, or Route .�� � C�y ��C /""`� Zip Cade .
s
SecKon No. Township Nam r No. Ranae No. Fire No. Counw
I �OP�^i� � ��� � � Plwne No. _� . � `
O` � ^ J
Power Suoo6er eaa.e..
ior �Comparry Name�
(Conhac�or or Ovmer Performing Installatio�)
�r�ng insrananon) ` I Phone No.
�/`�T�I�f/
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COpY