P - 81207�
U�877-718 �
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity a
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 ���
(651) 642-0800 www.electricity.state.mn.us "�'
Home Duplex Apt. Bldg. Other: New Addn
ommercial Industrial Farm Remod Repair
Air oner tg. Equip. Water Hh. Load Mgmt. Other:
ryer ange Elec. Heaf Temp. Service
„X" above the work covered by this reqvest. Enfer remarks in this space and on the back of the white copy only.
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Calculate lnspeciion fee - This lnspectio equest will no► be accepted wiihoui the correct fee:
Other Installations Fee # Service Enhance Size Fee # Circuifs / Feeders Fee
Mobile Home Park Stall 0 ro 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT�
Sign / Outline Ltg. Xfmr. t�1
Pool
I herebvi certifv that I insoected the elechical installation described herein on the dates stated:
� � Investigative Fee � � ( ��.�i�---� _�fi ��-�v J
THIS INSTALLATION MAY BE ORDERED DISC NNECTED �F NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PIEASE PRINT OR TYPE
Request Date � Rough-in inspecfion required? ❑ Yes ❑ No Inspection Other 7han Rough-In: eady Now � Will Call
You must call the inspecror when ready Date Ready:
licensed contractor ❑ company ❑ owner hereby request inspection of the above electricaf work at:
J Address (Sfrcet, Box,�� No.�f C�ily Zip Code
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Secfion No. Township Nam� or No. Range No. Fire No. . Coupij
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Occupant _ � Phone No.
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Power Suoo ier _ Address �
ELECTRIC, INC.
�� & �i�a�IrWg In
IN 55433
ny or Owner Perforrryi
�-
COPY
License N/o.
%Ol C� �1
S �- S 09v �
SEE INSTRUCTIONS ON BACK OF YELLOW COPY