P - 84711REQUEST FOR ELECTRICAL INSPECTION
4 61 _� 4 91 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800 •
home uuplex Apt. t51dg. Uther: New Addn
ommercial Indushial Farm Remod e 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 remarks in ►his space and on the back of ihe white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 'a , 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPEC70R'S USE ONLY TOTAL �^ �
Sign/Oudine Ltg. Xfmr. ���
Alorm/Remote Confrol
Swimming Pool
1 hereb certi fhaf I ins ted fhe elecfrical installafion dexribed herein on the dafes stated
Irrigafion Boom RoogM� pa�
Speciallnspec `
. Final �� po � ^ �
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months from validation date printed in fhis box.
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* 0 4 6 1 4 9� 3* PLEASE PRINT OR TYPE
Requesf Dafe Rou h-in ins fion r uired?
�—��� _(-� � r 9 P� eq ❑ Yes o Inspection Olher Than RougMn� Ready Now ❑ Will Call
Iou must call fhe inspeclor when ready� Dafe Ready:
I, licensed confractor ❑ owner hereby request inspection of the above electrical work at:
lob Address (Sheer, Box, or Roufe No.� C; P
i� 1!� 1 r n � !\ !1 i.- T� �/�1 n �. . Zi Code
Secfion No. � Township Name or No. Ranqe No. Fire No.
Occupant Phone No.
Lc� `i S %c� rn�� �f�n P �8
Power Suool�er
��� � Conhactor License No. Moster
nfracfor or Owner Performing Installafior
'� 3�'° 5T ,
. i( /ClW I T 1 �
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY