P - 83383REC�UEST FOR ELECTRICAL INSPECTION �•
(�(�7 /� Minnesota State Board of Electricity Q��^ �'
�J J" 1���`t � 1821 University Ave., Rm. S-128, St. Paui, fviN 55104
, � Phone (612) 642-0800 " '
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter rem rks in this space and on the back of Ihe white copy only.
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Calculate inspeciion Fee - This Inspection Request will not be accepted without the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
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 /��
Sign/Outline Ltg. Xfmr. l �
Alarm/Remofe Conhol
Swimming Pool
I hereb certi fhat I ins d the elechical installafion dexribed herein on the dafes sfafed
Irrigation Boom Roughan Dare
Special Inspec '
Final _
Investigative F
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
_, _, OFFICE USE ONLY This requesf void 18 months from validation dafe prinied in this box.
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* 0 6 9 1 1 6 4 8* r7�7
PLEASE PRINT OR TYPE
Request Dayf,�'/" I� Rough-in inspection required? ❑ Yes o Inspection Other Than RougMn: eady Now 0 Will Call
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( l� (You musf call the inspecfor when ready) Dale Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job�JiJr� (�or Rou �� ^/��� City �/ . Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Co ty ,n
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Occupant Phone No.
Power Sup li Address //�
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Elecfr' for �C m y Nam Conh tor Licens No. Master Lic. No. (Plant Elect. Only�
���C� �. ��C �D�l�
iling Addreu �Confracror or /ng/f, Performing I� Ilation) � i�� /J
�L%/ V/
Aufho ' ed Si n ure nhacfor or O r e Installafion) 2 6���� Pho e No, /�O
7
EB-0000 1 8/ 6 ST T OARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY