P - 80693.,_ . _ -
78?�°�63 �
Home Duplex
REGIUEST FOR ELECTRICAL INSPECTION `� •.
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 "�'
. Other: New � Addn
� ommercial Industrial Farm Remo Re
Air Cond. Htg. Equip. Wafer Hfr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remar s in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted withoui 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 Am s Above 100 Amps
Transformer/Generotor INSPECTOR'S USE ONLY TOTAL ,... ,,
Alarm/Remote Control
Swimming Pool U �
I hereb certi Ihat I ins ed the electr'ical installation deuribed herein on the dafes sfated
Irrigation Boom RougFfln Date
Speciai Inspec '� �
Find Dat �
Investigative Fee p ��l��
THIS INSTALLATION MAY BE ORDEREU DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This raquest void 18 months from validation date printed in this box.
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LEASE PRINT OR TYPE
quesf Dafe Rough-in inspection required$ � Yes No Inspection Other Than RougMn: ❑ Ready Now Will Call
�y'q �You must call ihe inspector when ready) Date Ready:
licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
5 dress (Street, Box, w Route No.) �� Ciy� Zip`Code .
ction o. Towns ip N e or No. Rarge No. Fire No. Coun n
Power
Phone No.
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or Owner Perfo ing Insmllafion �
ictor or Owner Performin '
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STATE BOARD COPY - SEE
Conkacfor License No. Master Lic. No.
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TIONS (�@I QACK OF YELLOW COPY