P - 84214i �5�3-315 �
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"X" above the work
REGIUEST FOR ELECTRICAL INSPECTION -
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 `
Phone (612) 642-0800 "�'
Industrial Farm
}itg. Equip. Water Htr. Load Mgmt. Other:
Range Elec. Heat Temp. Service
:overed by this request. Enter remarks in this space and on
of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not 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 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL L
L
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins ed the elecirical installation described herein on the dates stafed
Irriqation Boom RouaMn Date
Fee
� Investigative Fe� v v� v � L .. "' 1'� -"'�,� v
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MOIVTHS.
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OFFlCE USE ONLY This request void 1 S months from vaiidation date prinfed in this box.
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* � 5 5 3 3 L 5 3* PLEASE PRINT OR TYPE
Requ�sf Date � Rou h-in ins tion r uired?
�1'� g pec eq ❑ Yes No Inspection Ofher Than Rough-In: ❑ Ready Now Will Call
��' � (You must call the inspecfor when ready) � Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address (Sheet, Box, or Route No.� City Zip Code ��
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Secfion No. Township Name or No. Range No. Fire No. Coun� �.
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Power Supplier � Ad iess
Elechical �o�h�a'fN�Cupary N��EL.ECT.� �NCi. C acfor License
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STATE BOARD COPY - SEE INSTRUCTIONS
Phone No.
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No.
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