P - 83489REQUEST FOR ELECTRICAL INSPECTION --
6��=� 6 5 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 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. Enier remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without 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 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT� �
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
I hereb certi fhaf I ins ted the elechical installation described herein on fhe dates sfafed
Irrigation Boom RougMn Date
Special Inspec �
Final Dafe '"% _ �
Investigative Fee �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe printed in ihis box.
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PLEASE PRINT OR TYPE
Re uesf Dafe '�� Rough-in inspecfion re uired?
q ❑ Yes o Inspecfion O�er Than Rough-In: eady Now � Wi11 Call
�You musf call fhe inspecbr when ready) DaM Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheef, Box, or Roufe No.) � Ci P
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Secfion No. Township Name or No. Range No. Fire No. County
Ocpupa � �O �
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Power Suoolier . � � � � � – " � • � �
ical Confractor �Com y Name
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4�a ling Address (Confracfor or Owner erf rming Installation�
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t�pi�nz�d Signature (Confractor or Owner Performina Insfallationl
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STATE BOARD COPY - SEE
License
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ON BACK OF YELLOW �
ister Lic. No. �Nant EIecY. Onh
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