P - 81230„ REQUEST FOR ELECTRICAL INSPECTION
��� � � � � /I � Minnesota State Board of Electricity
_ �t 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
ome Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. $ervice
"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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Calculate Inspeciion Fee - This Insp�
Other Fee
Mobile Home Park Stall
Sheet Ltg./Traffic Sig.
Transformer/Generator
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Pool
Irriqation Boom
i equesi will not be acce
# Service Entrance Size
0 to 200 Amps
Above 200 Am
INSPECTOR'S USE ONLY
I hereby certify that I inspected the electrical
RougMn
the correct fee:
# Circuits/Feeders
0 to 100 Amps
Above 100 Ai
Fee
TOTAt�,�' �
GlJ
herein on the dates
_ THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf v�id 18 months from validafion date printed in this box.
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* 0 8 3 9 8 6 4 6* �oZ 70�
PLEASE PRINT OR TYPE
Requesf Dafe � Rough-in inspecfion required2 ❑ Yes No Inspecfion Other Than Rough-In: eady Now 0 WiA Call
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�You m�st call the inspedor when ready) Date Ready:
I, �censed contractor ❑ owner hereby request inspection of the above electrica) work at:
Job Addres ( eet, , or�pYlvl�o.) City Zip Code
7�%� /.l�' ��- �i�l�
Section No. Township,Name No. Range No. Fire No. C ny
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Occupanf � � Phone No.
Powe� Suoolier Addresy� C //�� �
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n�a e) �/ � Coyqacfor Li �ns� 9„���
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or or�n�Performing In�on) /�
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�ol�ctor or �ec-D�rformina InsfallaKon)
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STATE BOARD COPY - SEE INSTIlUCTIONS ON BACK OF YELLOW COPY
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