P - 80100REGIUEST FOR ELECTRICAL INSPECTION
� 'a Minnesota State Board of Electriciry `:�
� � � � � � � � 1g21 University Ave., . S-�8, St. Paul, MN 55104 ��
Phone (612) 6 -D�00�/ �� `�'
.4 c^'s�
� ome Duplex Apt. Bldq. Other: �'t ew Addn
Commercial Industrial Farm G{U.f
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 this space and on
copy
Calculate Inspection Fee - This Inspection Requesi will not be accepied withoui ihe correct fee:
Other # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park i e., 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Tronsformer/Generator INSPECTOR'S USE ONLY TOTAL a
Sign/Outline Ltg: Xfmr. �� �
Alarm/Remote Confro�
Swimming Pool
I hereb certi fhot I in fhe el ical insfallafion described herein on the dafes sfafed
Irrigation Boom Rouglfln Da
Speciallnspection � ��Zd°^�s�
F,�� °�l d�
Investigative Fee
_ THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 ONTHS.
OFFICE USE ONLY This request void�monlhs (rom validation date prinfed in this box.
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PLEASE PRINT OR TYPE
Request Rougffin inspecfion required? Yes ❑ No Inspecfion Ofher Than Roughan: ❑ Ready Now Will Call
� b� (You must call the inspector when ready� Date Ready:
I, ❑ licensed contractor � owner hereby request inspection of the above elechical work at:
Job Address (Streef, Box, or Roufe No.) Ci1y Zi Code
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Secfion No. I Townshi,Name or No. v " I�ta��o.�
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Power Supplier q���
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Elechical Confracror �Company Name�
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Mailing Address (Conhacror w Ow�r Performing Installolion)
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Aufhorized 5'i�ture (Confracfor or Owner Performing Installa6on�
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Phone No.
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Confracfor License No. Master Lic. No. IP
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY