P - 82893REQUEST FOR ELECTRICAL INSPECTION
5 7 5 w� C � Minnesota State Board of Electricity
, � 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm emod Re air
Air Cond. Htg. Equip. Water Hh. 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 ihe white copy only.
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Calculate lnspection Fee - This lnspection Requesl wi!! nol be accepted wiiiw�t ►he correc� fee:
Other Fee # Serv' rance ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 200 ps 0 to 100 Amps
Street Ltg./Tra$ic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator �NSP�� SE�oN�� ���� _ � TOT `�. I
Sign/Outline Ltg. Xfmr. c���
Alarm/Remote Conhol t
Swimming Pool �'��.: V
I here certi lfiat I ins elechim msla ahon described herein on the dales staFed
Irrigation Boom RougMn �
Special Inspection
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Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY Tfiis request void 18 months from wlidation date printed in this box.
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Requesf DaM Rough-in inspecfion required$ ❑ Ves No Inspeclion Olher Thon RougMn: eady Now ��II Call
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I, licensed conhactor ❑ owner hereby request inspection of the above elechical work ah
Job Address (Street, Box, or Route No.� Ciy Zip Code
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Seclion No. Township Name w No. Ran No. Fire No. Couny
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� n�Phone No.
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Power Supplier q�Jd�
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Electrical Conhacror �Company Name) Contracior li�nse No. Masrer lic. No. �Plant Elect. Only)
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Mailing Address �Conhacror or Owner PerForming Inslallation)
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Au ignature r Owner Performing Installafion) Phone No.
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E 1A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY