P - 82809,, REQUEST FOR ELECTRICAL INSPECTION ,��
5� n� 516 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 Re air
Air Cond. Htg. Equip. Waier Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in ►his space and on tl�e back of the whife copy only.
Calculaie Inspection Fee - This Inspection Request will not be acce
Other Fee # Service Entrance Size
Mobile Home Park Stall 0 to 200 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am
Transformer/Generator INSPECTOR'S USE ONLY
Sign/Oudine Lig. Xfinr. ��. .2 _�a.� o
Alarm/Remote Control N Gni� q-� q
t..,�mm�,,., P.,.,I �.-Y- `b/
without the correct fee:
Fee # Circuits/Feeders Fee
0 to 100 Amps
Above 100 Amps
TOTAL,�. S�
/
the electrical installafion described
Investigafive Fee �L ����`�' I��L X�( /� e�-
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OfFlCE USE ONLY This request void 18 months 6om validaKon dafe printed in this box.
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* � 5 3 2 5 L 6 2�c PLEASE PRINT OR TYPE ��
Reques� Rough-in inspecfion required2 ❑ Yes ❑ No Inspeclion Other Tiian Roughan: ❑ Ready Now � Will CaN
�D . �You must call the inspector when ready) Date Ready:
I, ❑ licensed controctor,�"owner hereby.request inspection of the above electrical work ah
Job Address (Street. Box or RoWe No.) Ciy ! Zip Code
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Seciion No. Township Name w o. Range No. Fire No. Cou
30 °� �
oa��r . , rh� No.
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Power Suoolie�
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Mailing Address (Conh�rJpr Owner Perfurming Insfaflafion�
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Conhacfor License No. . Mash
er Performing In Ilati 6 3 4 9 p
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STATE BOARD COPY - SEE INSTRUCiIONS ON BACK OF YELLOW COPY