P - 82960REQUEST FOR ELECTRICAL INSPECTION ��-
5 6 6�� 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 Addn
Commercial IndusFrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ►he work covered by this request. Enter remarks in this space and on the back of the whiie copy only.
l.�.� �'R � ����u � �
Calculate Inspection Fee - This Inspection Request 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/Generaror INSPECTOR'S USE ONLY TOTA� �p
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I in the electriwl installafion dexribed herein on the dales staled
Irrigation Boom RougMn Dule
Special Inspectio '
Final
Investigative Fee
THIS INSTA�.LATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MO S.
OFFICE USE ONLY This request void l�ths from validafion dale printed in this box.
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* O S� E� 2 8 7 9 * PLEASE PRINT OR TYPE
Request fe Rough-in inspecfion required$ ❑ Yes No Inspecfion Olher Than RougMn: Ready Now ❑�II Call
� (You must call the inspector when ready� Date Ready:
I, icensed conhactor ❑ owner hereby request inspection of the above elecfrical work ah
.bb Address (Street, Box, w Rou�e No.) City Zp Code
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Seclion No. Township Name or No. Range No. Fire No. Counly
R�`d le j7�l110
Occupant - � Phoee No. ��
� GU; � 6 . ���' � � 9
Power 5 pplier Address
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ie� ConhocFor License No. Master Lic. No. (Plant
�lP�' � ���. � � r�� �"'�9 -
�er Performing Installation)
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Owner Performing Insfallationj 1re No.
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STATE BOARD UC710NS ON BACK OF YELLOW COPY