P - 83455REQUEST FOR ELECTRICAL WSPECTION °"
��r� ��� r� � Minnesota State Board of Electricity
�� L. 1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104 �`
' Phone (612) 642-0800 `���
Home Duplex Apt. B(dg. Other: New Addn
ommercial ndustrial Farm Remod Re air
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 the white copy only.
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Colculaie Inspeciion Fee - This lnspectron uest will not be accep�ed withou► �he correct fee:
Other Fee # Service Entrance Size Fee # Circuits/feeders f
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg./Traffic $ig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�v TOTAL �
Sign/Outline Ltg. Xfmr. �jEf' �'''L``� �
Alarm/Remote Control •
„ I hereby certify that I inspected the electrical installation
Date
Investigative Fee ���- """�� ,�"�o
THIS INSTALLATION MAY BE ORDERED DISCONNECT'ED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validaKon date printed in fhis box.
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* 0 7 2 4 5 5 2 5� �1,3 �%
PLEASE PRINT OR TY�PE
Requesf Dafe , � Rou h-in ins ection re uired$ ❑ Yes
g p q ❑ No Inspection Other Than Rough-In: Ready Now 0 Will Call
(You must call the inspector when ready� Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1 Address (Sheef, Box, w No.) Ci Zip Code
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$ecfion No. Township Name or No. Range No. Fire No. County
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Occupan . Phone No.
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Signature �Co r or
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COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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