P - 84554REQUEST FOR ELECTRICAL INSPECTION
'�4 i. J, � 0 6 4 Minnesota State Board of Electricity
, 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone(612)642-0800
Home Duplex Apt. Bldg. Oth r: IL1ew A�
Commercial Indusfrial Farm emod RE
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 bock of the white copy only.
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Calculate Inspection Fee - This Inspection Requesi will nof be accepted withouf the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
bile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR�S USE ONLY T�� �.
line Ltg. Xfmr.
mote Control
� Pool
Boom
that I inspecled ihe electrical installafion dexribed herein on fhe dates sfated
Imestigative Fioal - �t p� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFf10E USE ONLY This request void 18 months 6om validation date printed in this box.
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PLEASE PRINT OR TYPE
:°� Rough-in inspecfion requi�ed2 ❑ Yes o Inspecfion O�er Than Rough-In: ❑ Ready No i I Call
S � �You must caN fhe inspector when ready� Dafe Ready:
�nsed confractor ❑ owner hereby request inspection of the above electrical work at:
ess (Sheef, Box, or Roule N� Cily _ Zip Code
SecM1on No. Township Name or No.
Occu t
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Power Supplier
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Elechical onhaclor (Company Name)
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Mailing ljddress (Conhac or or Owner
No. Fire No. County �
Phone No
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ControMor License No. Masfer Lic. No. (Flanf Elect.
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(Conhacror w Owner Performing Installafion) �� O � p
ATE BOARD COPY - SEE INSTAUCTIONS ON BACK OF VELLOW ccfav
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No.
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