P - 83453REGIUEST FOR ELECTRICAL INSPECTION "'E
'] n QQ Minnesota State Board of Electricity � �
1� 4� V V O � 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �f�`
� _ Phone (612) 642-0800 -�'�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Hfg. 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 copy only.
Calculate Inspec►ion Fee - This Inspection Request will noi be accepted wifhoui the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transforme��Generator INSPECTOR'S USE ONLY TO�� �
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi fhat I ins ted the electrica) installation described herein on the dafes sfuted
Irrigation BOOm RougV�ln Da ��, �f �
Special Inspecti �� � —�O'� �'
Investigative Fee ' Final Da
THIS INSTALLATION MAY BE ARDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONT S.
OFFlCE USE ONLY This roquesf void 18 months from validafion date printed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Date� � Rough-in inspecfion required? �Yes ❑ No Inspecfion Ofher Than RougMn: eady No ill Call
� (You must call ihe inspector when ready) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addreu (Skeet, Box, or Roufe No.) City Zip Code
-c , s. � �
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Section No. Township Name or No. Range No. Fire No. un
� �,�,�,.�,�
Occupant I Phone No.
Power Suoolier _ � Address _� 1 P_
pany Na � Conbacror License No. Masfer Lic. No. (Pbnt Elecl. On
�( e cJi� Y� i� C�P� C�O'��! J
or or Owner Performi Installation�
i�ye�A ��f'c1 Z �r ar� � �r� N
ihaclpror ne rfo i Installallon) �/'� /� �� Phon������
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY