P - 81040REQUEST FOR ELECTRICAL INSPECTION
Q/� j�(� S� � Minnesota State Board of Electricity
v`t v 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 white cop only.
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Calculol� lnspec n fee - This lnspection Requesi wiU not be accepied without ihe correci fee:
Ot er Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 fo 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ON�Y TOTAi.7j�� �y�
Sign/Oudine Ltg. Xfmr. .��J uCJ
Alarm/Remote Control
Swimming Pool
1 hereb certi that I ins ected the electrical installafion described herein on the dates stated
Irrigation Bo RougMn Dare
Specia) Ins i n
Investigative Fee Fiiwl Date�6 � .y+;
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THIS tNSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MOKTHS.
. OFFICE USE ONLY Thia request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rou h-in ins on r uired� ❑ Yes
g pecfi eq ❑ No Inspecfion Ofher Than Rough-In: Ready Now ❑ Will Call .
�° • (You must call the inspeclor when ready� DaTe Ready:
I, icensed confractor ❑ owner hereby request inspection of the above electrical work at:
Job Addre �Street, Box, or R o.) Ciy ` /� Zip Cod���
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$ection No. Township Name or No. Ronge No. Fire No. Coun //�;�' /'�.
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Occupant Phone No.
ct. s�a -�
Power Suoo �er . Addro«
Contractor
CTRIC.INC. ��o.
SignoNre �Conhacror er Pe Install 'on — Phone No.
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11 /96 ST O D COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY