P - 84696RE(�UEST FOR ELECTRICAL INSPECTION -
nr �/� � Q�� Minnesota State Board of Electricity _ •
r' `v � 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. 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
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Calculate Inspection Fee - This Inspection Request will not be
Other Fee # Service Entrance ;
Mobile Home Park Stall 0 to 00 Amps �i
Sfreet Lfg./Traffic Sig. Above 200 i
Transformer/Generator INSPECTOR'S USE ONLY
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins cfe�
Irriqation Boom R,,,,,,�„
New I I Addn �
copy only.
without the correct fee:
Fee # Circuits/Feeders
j 0 to 100 Amps
Above 100 Am
the elechical installaKon described herein
Dore
Fee
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stafed
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USF ONLY This request void 18 months from validafion date prinfed in this box.
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PLEASE PRINT OR TYPE
Requesf Date Rough-in inspection required? ❑ Yes o Inspection Ofher Than RougMn: eady Now ❑ Will Call
�'� D�— � 7 �You musf call the inspector when ready� Date Ready: '7„ !'Q
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Addreu �Sfreef, Box, or Roufe No.) Cily � Zi Code
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Secfion No. Township Name or No. Ranqe No. Fire No. CounN
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hoctor (Company Name)
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STATE BOARD
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Phone No.
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Conhacior License No. I Masfer Lic. No. (Planf Elect. Only)
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P SEE INSTRUCTIONS ON BACK OF YELLOW CAPV