P - 80696REQUEST FOR ELECTRICAL INSPECTION
7 C�. L; � O�� � Minnesota State Board of Electricity �
��� `� 0 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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' Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial 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 re est. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspec►ion Fee - This Inspection Request will not be accepted wi►hout 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 Amps
Transformer/Generator INSPECTOR's uSe ON�r T
Sign/Outline Ltg. Xfmr. '��
Alarm/Remote Control
Swimming Pool
I hereb ceAi that I ins the electrical installation described herei� on the dafes sfated
Irrigation Boom Rouglfln Dare
Special Inspectio
Final Da
Imestigative Fee � --
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
_ OFFICE USE ONLY This request void 18 months hom validafion date prinfed in this box.
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PLEASE PRINT OR TYPE
� Rou Irin ins fion r uired$ s
9 P� e9 ❑ No Inspecfion Other Than Rough-In: ❑ Ready Now 0 Will Call
�You must call the inspecfor when ready� Date Ready:
contractor ❑ owner hereby request inspection of ihe above electrical work at:
Box, or Route No.) Cify . Zip Code
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ishio Name or No. Range Fire No Coun
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Power upplier
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Elechical Conhacror (Company Name)
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Mailing Ad ress (Conkacfor or Owner Pedormin Ir
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Authorized Signafure (Conhacror or Owner Pedormi
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Contractor License No.
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STATE BOARD COPY - SEE IMS� ON BACK OF YELLOW COPY
No. 4 i 2�