P - 841315�7-�51 �
Home Duplex Apt.
Commercial Industrial Farm
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612)642-0800
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Addn
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
C�ema�e. �:S�.QC'rr�.c.�, -�o � �c�c3.. '�A /�
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Calculate Inspecfion Fee - This Inspection Request will nof be accepted without the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Ai
Transformer/Generator INSPECTOR'S USE ONLY TOT
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
I hereb certi that I inspecfed the electrical installation described herein on the dah
Irrigation Boom Rough-In Date
$aecial Inspe rt c �.; , , . - _
Fee
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 1 8 monihs from validation dafe printed in fhis box.
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Request ate Rough-in inspecfion required? ❑ Yes No Inspection Other Than Rough-In: ❑ Ready Now Will Call
`a� ���� (You must coll ihe inspector when ready� Dote Ready:
I,� licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address �Street, Box, or Route No.) City Zip Code
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Section No. Township Name or No. . Range No. Fire No. County
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` Phone No.
Address
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_ a Con}ractor License No.
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(Conhactor or er Performing Installation�
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pure (C hactor or OwneS-Performin stal ion�
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Masfer Lic. No. (Plant Elecf. Only�
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