P - 84005501�-173 �
REQUEST FOR ELECTRICAL INSPECTION
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. Enter remarks in this space and on the back of the whiie copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted wifhout ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps _,Tt�
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. OZ% •�p
Alarm/Remote Control
Swimming Pool
I hereb certi fhat I ins ecfed fhe electrical installation dexribed herein on the dates sfated
Irripation Boom p,,,,,,�,,., „_._
Investigative Fee — -g � � � ' ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITIiIN 18 MONTHS.
OFFICE USE ONLY This request void I B months from validation date printed in fhis box.
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Request ate ,+7 Rough-in inspection required? ❑ Yes No Inspection Other Than Rough-In: Ready Now ❑ Will Call
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I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
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