P - 83642I � I ��
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REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Other: New
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` Commercial Industrial Farm Remod
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 copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Ar
Transformer/Generator INSPECTOR'S USE ONLY TOT,
Sign/Outline Ltg. Xfmr. '
Alarm/Remote Control
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Fee
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I hereb certi that I ins fed fhe eleckical insfallation described herein on the dofes stated
Irrigation B Rough-In ��e
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Investigative Fee � ,[/ � / � �'— ( t�
THIS INSTALLATION MAY BE ORDERED DISCONN D IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 month m validafion dafe prinTed in fhis box.
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Reque f fe
/_���� � Rough-in inspection required? ❑ Yes No Inspecfion Other Than RougMn: Ready Now ❑ Will Call
� �You musf call the inspector when ready� Date Ready:
I, �,licensed contractor ❑ owner hereby request inspection of the above elechical work at:
Job Address (Sireef, Box, or Roufe No.) Ci , Zip Code
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Section No. Township Name or Range No. fire No. Couny y�
Power Supplier
EI 'cal Confracfor (Company Name)
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Mail�Address ( or�cror or; �
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Authorized Sign ture (Conhactor g�0�
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i8-0OOOlA-11 8/96 S�
Phone No.
Confr to te No.
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Elect. Only�
Phone No.
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