P - 80276REQUEST FOR ELECTRICAL INSPECTION ��
7���� 0 Z � Minnesota State Board of Electricity !3
- 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone (612) 642-0800 `'�`
ome 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 covere�s re ue_q st. Enter 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 withovi the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps O
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. Q.
Alarm/Remote Control
Swimming Pool ` �
I hereb cerfi thaf I ins ted the elechical instollation described herein on the dates sfated
Irrigation Boom Roughdn Dare
Special Insp �-�`�"-'�' `d _�
Investigative ee F� �" e -'Z- �'-�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validation dafe printed in this box.
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PLEASE PRINT OR TYPE
Requesf Daf Rou h-in ins ion r uired$ Yes
g pecf eq ❑ No Inspection Ofher Than Rough-In: eady Now Will Call
! (`(ou must call the inspector when eady) Dafe Ready: -
I, ' ensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Roufe No.) City � Zip Code
�a�
Secfion No. Township ame or N: Range No. Fire No. Cou
Occupant � Phone No.
� s633���r
Power Supplier Address
Electric�Ff�nhacfor (Company Name) � Controcfor License No. Masfer Lic. No. (Planf Elect. Only)
or vwner re rormmg Ins nano Phone No.
� 7�39 ds7 �86
STATE BOARD COPV -_ EE INSTRI1CTnNR ON FtACK nF VELLAW COPV