P - 83195REQUEST FOR ELECTRICAL INSPECTION
4 J�! 2 9 6 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
' Phone(612)642-0800
e Duplex Apt. Bidg. Other: � New
Commercial Industrial Farm � Remod
Air Cond. Htg. Equip. Water Htr. load Mgmt. r:
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
Calculate Inspection Fee - This Inspection Request will not be accepted wifhovt fhe correct fee:
Other Fee # Service Entranc ize Fee # Circuits
Mobile Home Park Stall -200 Amps 0 to 100 A
Street Ltg./Traffie Sig. Above 200 Am s Above 100
Transformer/Generator INSPECTOR'S USE ONLY
mote Coohol
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Fee
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Investigotive Fee ( !�
THIS INSTAU.ATION MAY BE ORDERED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request vad 18 months from validotion date prinfed in this box.
_ _ . � 02,5- sd
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* � 4 3 L 2 9 6 3* PLEASE PRINT OR TYPE
RequesT ate � Rough-in inspecfio� required? ❑ Yes ❑ No Inspeclion O�er Than RougMn: ❑ Ready Now � Will Cali
(You musT cail the inspecfor when ready� Date Ready:
I, licensed contractor ❑ owner hereby request inspection of ihe above electrical work at:
J Addreu (Skeet, Box, w�pute No.) Cily ` Zip Code
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STATE BOARD COPY - SEE INSTRLCTIONS ON BACK OF YELLOW COPY