P - 83168REQUEST FOR ELECTRICAL INSPECTION
6������ � Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
� � Phone (612) 642-0800 "�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod e air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above Ihe work covered by this request. Enter remarks in ihis space and on the back of the white copy only.
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Colculate Inspection Fee - This Inspection Request will not be accepted withou► the correct fee:
Other Fee # Service Entrance Size Fee # CircuitsjFeeders Fee
Mobile Home Park Stall 0 ro 200 Amps to 100 Amps
Street Ltg./Traffic $ig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
$ign/Outline Ltg. Xfmr. ��. S �
Alarm/Remote Conhol
Swimming Pool
I hereb certi Ihat I in the electrical installotion described herein on the dates stated
Irrigation Boom Ra,ph-In Dare
THiS INSTALLATION MAY BE ORDERED DISCONNE�TED IF NOT COMPLETED WfTHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 rtwnths from validafion date printed in this box.
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PLEASE PRINT OR TYPE �
�uest �� Q� Rou h-in ins on r uired?
g pecli eq ❑ Yes o Inspecfion Other Than Ro�gMn: ❑ Reody Now ill Call
—i (You must call the inspecror when ready) Date Ready:
I, licensed conhactor ❑ owner hereby request inspection of the above elecfrical work at:
lob ddress (Streef, Box, or Roufe No.) City t Zip,�`�/
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Section No. Township Name r No. ange No. Fire No. Coun
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Phone No.
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Na e� r Conkaclor License Na . Masfer Lic. No. �Planf Elecf. Onl;
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Owner Perform'n tallafion�
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