P - 82812� REQUEST FOR ELECTRICAL INSPECTION �����o:.
��� � � � � � � Minnesota State Board of Electricity
� 1821 University Ave., Rm. S-128, St. Paul, WIN 55104
Phone (612) 642-0800 �
Home Duplex Apt. Bldg. Other: New Addn
Commercial dustrial Farm Remod Re ir
Air C Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
X" above ihe work covered by this request. Enter remq in fhis space and on the back of the while copy only.
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Calculate Inspection Fee - This Inspection Request will not be pted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT/�L� ��
Sign/Outline LFg. Xfmr. �
Alarm/Remote Confrol
I herebvi certiH fhaf I insoected the
Dak
Investigative Fee r�� �� -� Z�' G�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIIV f8 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validafion dafe printed in this box.
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PLEASE PRINT OR TYPE
Request DaTe . �. Rou h-in ins on r uired? ❑ Yes
g pecli eq ❑ No Inspection Other ihan Roughdn: eady fVow � Will Call
�`fou musf call ihe inspector when ready� Oate Ready:
I, censed conhactor ❑ owner hereby request inspection of the above elechical work at:
Job ddreu � eet, Box, or Roufe N � � City Zip Code
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Secfion No. iownship Name or No Range No. Fire No. Counfy
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���P°^� � �\ %i Phone No.
Power Sui
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ized $ignaNre
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ECTRIC. INC.
Owner
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- S�E INSTRUCTIONS ON BACK OF
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Masfer Lic. o. �Plant Elecf. Only)
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Phone No.
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