P - 83775REQUEST FOR ELECTRICAL INSPECTION
5�C �„ C�� � Minnesota State Board of Electricity
J J 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. Service
"X" above the work covered by this reGuest. Enter remarks in t s space and on the back of the white copy only.
i ��� Cl/h� ��r
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/Generator INSPECTOR'S USE ONLY TOTAL��
Sign/Outline Ltg. Xfmr. l'�
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins d the electrical installation described herein on the dafes stated
Irrigation Boom Rough-In ��e
Special Inspe ' rp-
Final D
Investigative F `• -
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 monfhs (rom validafion dafe printed in fhis box.
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* D 5 2 S S O 5 4* PLEASE PRINT OR TYPE
Request D// ��� Rough-in inspection required? ❑ Yes �1Vo Inspection Other Than RougMn: eady Now � Will Call
� (You must call the inspecfor when ready) � Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above elechical work at:
1ob Addre;s reet, Box, o�r Ro o.) City Zip Code
����/d�r � �
Section No. Township Name r No. Range No. Firc No. C nty j. �
Occupant //
Power S ao er/1
n
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ny � ,
� C°G��`%�z �t�.
or Owner Perforr�p Installation),.� __
Owner
Phone No.
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r Lice se No.
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INSTRUCTIONS ON BACK OF YELLOW COPY
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