P - 84653{� REQUEST FOR ELECTRICAL INSPECTION
�t �� - 5 4 4 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �.
Phone (612) 642-0800 '�i;� �/
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Home Duplex Apf. Bldg. Other: New ddn
ommercial Indushial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmf. Other:
Dryer Range Elec. Heat Temp. Service
"X" above fhe work covered by this request. Enter remarks in� is space and on the back of the white copy only.
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Calculate Inspection Fee - T ih s Inspecti equesi will not be accepted withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps �
Street Ltg./Traffic Sig. Above 200 Am s Above 100
Transformer/Generator INSPECTOR•s usE oN�v . TAI�D ,,�7'j
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Sign/Outline Ltg. Xfmr. �G��,.� (2it.u•�� O
Alarm/Remofe Control
Swimming Pool
I hereb certi fhat I ins fed fhe electrical insfallation described herein on the dates stafed
Irrigation Boom Rough-In Jp�� q /�j+
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Invesfigative Fee — � " ��.v. _ ° �� / �'`
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation dafe printed in this box.
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Requ st Date Rough-in inspection required? es •
❑ No Inspecfion Ofher Than RougMn: ❑ Ready Now Will Call
� (You must call the inspector en ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address �Sfreet, Boy�,.q` Rou�e No.) �> Ciy . � Zip Code
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Section No. I Township Name o� No. Range No. Fire
Phone No.
Co cfor license No. Master
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(Confractor or