P - 8319052�-545 ��
Home Duplex
Commercial Industrial
Air Cond. Htg. Equi�
Dryer Range
"X" abov th work covered. b}
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RE(�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 '�'
, Other: New Addn
farm Remod Repair
Water Hh.
Elec. Heaf
�uest, Enter
Mgmt. Other:
Service
in thi spa e and on the back of the
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Calculafe Inspection Fee - This Inspection Request will not be accepted wifhout fhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 ro 200 Amps 0 to 100 Amps
Sireet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL�p ,
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
$Wimf111n9 POO� I herebvi ceAifv that I insoecled the electricol installation described herein on the dates stafed
Special Inspec#'�(in i,� (j ; _ � � '-Lv
Imestigative fee F��� -�
THIS INSTALLATION MAY BE ORDERED CTED IF NOT COMPLETED WITHIN 18 MONTHS.
� IISE ONLl� ihis requasf void 18 months (�om validafion date printed in this box.
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�K �.5 2 2 5 4 5 3�c PLEASE PRINT OR TYPE
Requesf Date . 4 Rough-in inspecfion required? Yes ❑ No Inspeciion Other Than RougMn: ❑ Ready Now � Will Call
� 7j (You must mll the inspecfor when ready) Date Ready:
I, ,�jl'censed contractor ❑ ow�er hereby request inspection of the above elechical work ah
Job Address (Street, Box, or Rou�e No.) Ciy � Zip Code J
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SeMion No. Township Name or No. Range No. Fire No. C ny A
Power
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Signature �Conhactor or Owner P rmin fallafion� �. �O ��_�� P
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11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON 6ACK OF YELLOW COPY
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