P - 83527RE(1UEST FOR ELECTRICAL INSPECTION
7 n�� O�� � Minnesota State Board of Electricity �
c a1 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �`
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercia) ' dustrial Farm Remod e air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other.
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enier remarks in this sppce and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Reques► 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 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTALi� �
Siqn/Outline Ltg. Xfmr. �
mote Control
� Pool
Boom
Dafe
Imestigative fee'�' " 'L v ••••-� _�
THIS INSTALLATION MAY BE ORDERED DISCO TED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE l�E ONLY This request void 18 months from validation date printed in this box.
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* 0 7 2 5 0 3 7 6* �f'a ��
PLEASE PRINT OR TYPE
Requesf Date Rough-in inspecfion required? ❑ Yes No Inspection Other Than Rough-In: ady Now ❑ Will Call
1�— 1� (You musf call the inspector when ready) � Date Ready:
I, �licensed contractor ❑ owner hereby request inspection oF the above electrical work at:
Job Address (Street, Box, or Rcpte No.� _ City ` � Zip Code
No. I Township Name or No. I Range No. I Fire No.
Occupant
�Company Name) � � Conhpcior license
�Conhacfor or Owner
Phone� � � _ ( ���
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7
STATE BOARD COPV - SEE INSTRUCTIONS ON BACK OF YELLOW COPY