P - 84208REGIUEST FOR ELECTRICAL INSPECTION °� �
5� l�1 -- 2 4 9 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 Addn '
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter re arks in this space and on the back of the white copy only.
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Calculate Inspeciion Fee - This Inspection Requesi will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile 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 TOTA����
Sign/Outline Ltg. Xfmr.
Alarm/Remote Confrol � �
Swimming Pool
I hereb certi that I ins cted !he electrical installation described herein on the dates stated
Irrigation Boom Rough-In oare
Special Inspectio l
Fino� =��-� pa'
Investigative Fee � ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation dafe printed in this box.
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* � 5 6 0 2 4 9 5* PLEASE PRINT OR TYPE
Requesf Daje /� Rough-in inspection required? ❑ Yes No Inspecfion Ofher Than RougMn: ❑ Ready No Will Call
� (You musf call the inspector when readyJ Date Ready:
I, �ensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfr t, or Rou o.) City � Zip Code
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SeMion No. Township Name or No. Range No. Fire No. Co ty
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Occupanf
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Power Supplier ,� � /
Maj�iqg�� ss �Confr or �r�;�
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I Phone No.
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dress � //� `7� �%
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Conh ror Licen e No.
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� YELLOW COPY