P - 803868?E=188 �
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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Commercial Industrial Farm Remod Re
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.
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Calculate Inspection Fee - This ►nspection Requesf will not be accepted without ihe correct fee;
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps p� 0 to 100 Amps `
Street Lfg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONCY TO /L
Sign/Outline Ltg. Xfmr. �,(Q t �
Alarm/Remote Control
Swimming Pool I hereb certi that I ins the electrical installafion described herein on the dates stated
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Investigat' f�e �- O- ��y—Of�
THfS INSTALLATfON MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
. OFFICE USE ONLT This requesf void 18 months 6om validafion dafe prinfed in this box.
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PLEASE PRINT OR TYPE
Requesf Rough-in inspection reqvired$ ❑ Yes o Inspecfion Ofher Than Rough-In: ❑ Ready Now Will Call
� (You must call the inspector when ready) Dote Reody:
I, lice sed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address (Sheet, Box, or Route No.� City Zip Code
30 Sr' ��r` �� �'-xl �.
$ecfion No. Township Name or No. Range No. Fire No. County _
Ocwpant
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Power Supplier
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Electrical Conhactor (Company Name)
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Mailing Address (Confracfor or Owner Pe rming Ins
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A ature (ConKactor or Owner Performin�
B-OOOOlA-11 8/96 STATE BOARD
Phone No.
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ConhaMrn License No. Master Lic.
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- SEE INSTRUCTIONS ON BACK OF YELLOW COPY