P - 82790REQUEST FOR ELECTRICAL INSPECTION
C%��� O� � Minnesota State Board of Electricity
V} O 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone {612) 642-0800
Home Duplex Apt. Bldg. Other: New
ommercial Industrial Farm Remoc
Air Cond Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ►he work covered by this request. Enter remarks in this space and on the back of the whi►e 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
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 TOTiAL
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Fee
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Alarm/Remote Confrol
Swimming Pool
I her cerli IIwT I ins the elechical inslallafion described herein on the dates staled
Irrigation Boom' '� RouyMo Dare
Speciallnsp � �
� Final � Dafe
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validation dafe printed in this box.
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IEASE PRINT OR TYPE
R�1 D� ��� Rough-in inspecfion required$ ❑ Yes No Inspacfion Ofher Than Rough-In: Ready Now 0 Will Call
�You musi call ihe inspecfor when ready) Date Ready:
I, licensed conhactor ❑ owner hereby request inspection of tfie above electrical work at:
Job Address (Shcet, Box, or Roufe No.� . C�� � Z�P� �
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Secfion No. Township Name or No, Ran9e No. , Fire No. Cou
CJ�upant �
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Power S plier Address
Elechical Conhacbr �Company Nome) � —
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Mailing Addr (Contracfor or Owner Perfwming Ins IaKop�
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Aufho zg ' nafure (Conkacfor or �wner PerFormina nstallati
Phone No.
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License No.
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BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY