P - 7978880�2-377 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 64 800
' Home Duplex Apt. Bldg. Other: O V ('".� New
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Commercial Industrial Farm � � J�� Remoc
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" bove the work covered by this request. Enter remarks in this space and on the back of the white copy
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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
Sheet Ltg./TrafFic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA4 � C�
Alarm/Remote Control
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I hereb certi thaf I i�s cfed the elecfrical installation described herein on the dales slaled
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Investigative Fee lv Z �
THIS INSTALLATION MAY BE ORDERED DIS NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE U3E ONLY This requesf voidy8' months 6om validation date printed in ihis box.
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PLEASE PRINT OR TYPE
Request Da / Rough-in inspection required? es ❑ No Inspection Other Than RougMn: ❑ Reody No ill Call
/o� t 9,0 � �`fou must call the inspector when ready) Dafe Ready:
I, Gcensed contractor ❑ owner hereby request inspection of the above elechical work at:
ob Address �Sheef, Box, w RouGe No.) City Zip Code
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$ection No. Township Name No. Range No. Fire No. Counly
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Phone No.
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Conhacror License No. Master Lic. No. �Planf Elecl.
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Address (Conkocfor or (�6iner Perfc�yf{ng Installation�
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ed Si e( nhactor erforming Installati Phone No.
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I A 8/96 STATE BOAR COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY