P - 82792REQUEST FOR ELECTRICAL iNSPECTION
6 4 7--� 6 9 � Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
� Phone(612) 642-0800
ome Duplex Apt. Bldg. Other: New Addn
mmercial Industrial Farm Remod
Air C . quip. 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 back of the white copy only.
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Calculaie Inspection Fee - This Inspection Requesf will not be acce�ou e:
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 Am s Above 100 Amps
TransFormer/Generator INSPECTOR'S USE ONLY TOTAL /_ ��
$ign/Oudine Ltg. Xfmr. � %� �
Alarm/Remote Confrol
Swimming Pool
I hereb certi that I ins the eleclrical installation dexribed herein on the dates sta�ed
Irrigation Boom RougMn Dare
Speciallnspectio . •
final
Investigative Fee -� �j'-O �
THIS INSTAL�ATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE I�E ONLY This requesf void 18 months from validation dafe printed in this box.
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* 0 6 4 7 6 6 9 1* �`�6�
PLEASE PRINT OR TYPE
Requesf Date ^ Rou h-in ins on r uved?
l g pecfi eq ' ❑ Yes o Inspeclion O�er Than Rough-In: Ready Now Q�II Call
d �`(ou musf call the inspecfor when ready) Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
lo Pd ress.�St�et, Box, �ut9 No.� �� City/ � J Zip Code
or No. � Range No. ' � Fire
Address
Name) �fn � • � Contrac�or License No. � Masfer Lic. No.
Owner
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1 6/96' � �
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY