P - 82125REQUEST FOR ELECTRICAL INSPECTION ��
�� Q°j �°�� f � � Minnesota State Board of Electricity �'
aJ 1. `�' 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us `���
ome Duplex Apt. Bldg. Other: New Addn
C mercial Industriol Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. $ervice
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspectio Requ t will not be accepted without the correct fee:
Other Installations Fee #$ervice Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stdll 0 to 200 Amps to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T� �l
Sign / Outl�ine Ltg. Xfmr. � 5U
Alarm/Remote Control
Swimming Po � �
I hereb certi fhal I ins ected fhe electrical installation described herein on ihe dates stafed:
Irrigation Boo Rough-In Date
Special Inspect
Final Daf
Investigative Fee � —
THIS INSTALLATION MAY BE ORDER@D DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monihs from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Dat � ` Rou h-in ins ction r uired?
�� g pe eq ❑ Yes o Inspecfion Ofher Than Rough-In: Ready Now ❑ Will Call
You must call fhe inspecfor when ready Dafe Ready:
I�icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job A ress Sfr , Box, o oufe N. ^/� /� City ��/ . Zip Code
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Secfion No. Township Name or No. Range No. Fire o. Coun ���
Occupant / // n �� /� Phone No.
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Power Suppli Address
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Elecfri �/`///� Nam� � Coycpctor Lic4,Qse N�a� Masfer Lic. No. (Planf Elecf. Only)
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Maili��ss (Confr for, Company or Owner P orming In II on
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Aufho ' ed Si afure racfor, ner Pe i�n Ilafion) / Phone� e����
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EB� -� � 99 srarF acfewn copv seE INSTRUCTIONS ON BACK OF YELLOW COPY