P - 80994.
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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612) 642-0800
Nome Duplex Apt. Bld . Other:
Commercial Industrial Farm
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 ►he whi►e
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Calculate Inspection Fee - This Inspection Reqvest will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feedei
Mobile Home Park Stail 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 �
TranSformer�Generator INSPECTOR'S USE ONLY TO
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimmin Pool
New
copy
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9 I hereb certi that 1 ins ed ihe electrical installation described herein on ihe dates stated
Irriqakion Boom ,,, ,_. _ Ro�al.i� Dare
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Fee
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Investigative Fee �� [
THIS INSTALLATION MAY BE ORDERED dSCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OF'FlCE USE ONLY This req�est void 18 monfhs from validation dafe prinfed in this box.
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LEASE PRINT OR TYPE
Requesf fe Rouglfin inspection required$ ❑ Yes No Inspecfion Other Than Rough-In: Ready ow ❑ Will Call
�You musf call the inspecfor when ready� Dare Ready: ,O .
I, licensed conhactor ❑ owner hereby request inspection of the above elechical work at:
lob Address (Sheet, Box, or Ro o.) City �+ Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Co ly
Occu n '
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Power Supplier AddrE
Elechi c�l Conhacfor �Compony Name)
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Mail' Address (Conhacfor r Owner Performirg InsMllation)
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Aufhorized Sjgn� �Conhacfor or ner Pe ing Installafion)
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License No.
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�96 • STATE BOARD Y- SEE INSTRUCTIONS ON BACK OF YELLOW COPY
(Plant Elect. Onlyl
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