P - 84722REDUEST FOR ELECTRICAL INSPECTION
/j 5��� O� Minnesota State Board of Electricity
"'* . 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� " Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New
Commercial Indusfrial Farm Remod
Air Cond. Htg. Equip. Water Hh. Load Mgmt. Other: ��� n� ��
Dryer Range Elec. Heat Temp. Service C
"X" above the work covered by this request. Enter remarks i is space and on the back of the white opy
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C culate Inspection Fee - This 1 tion Request will nof be accepied without the correct fee:
Other
Mobile Home Park Stall
Sheet Ltg./Traffic Sig.
Tra n sformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool
Irriqation Boom
Fee # Service Entrance Size Fee # Circuits/Feeders
0 to 200 Amps 0 to 100 Amps
Above 200 Am s Above 100 Ai
INSPECTOR'S USE ONLY TOT�
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only.
that I ins fed fhe elecfrical installation described herein on fhe dates sMted
Dafe
Fee
Invesfigative Fee �� ` � E "-- � �
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THIS INSTALLATION MAY BE ORDERED DISCONN CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months 6om validation dafe prinled in this box.
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* � 4 5 7 2 � 6 l+ * P ASE PRINT OR TYPE
Requesf D %C �j Rough-in inspecfion required? ❑ Yes o Inspection O�er Than Rougfrin: dy Now Will Call
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� �(�l (`/ou must call fhe inspecfor when ready� Daffi Ready:
I, censed conhactor ❑ owner hereby request inspection of the above elechical work at:
Job Addryss�eet, Box, oufe � j� Ciy .- // Zip Code
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Seclion No. Township Name or No. Range No. Fire No. C 1y /
Occupant
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, Conhpclor License
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Mailing Address �Conhacror or
Phone No.
Lic. No.
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