P - 8473949,7-=739
Home Duplex
Commercial Indushi
Air Cond. Htg. E<
Dryer Range
"X" above the work covered
RE�UEST FOR ELECTRICAL INSPECTION -�
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Apt. Bldg. Other/:� J� New Addn
�I Farm i"/,/ I�IOL Remod Re ir
uip. Water Hh. load Mgmt. Qfher:
Elec. Heat Temp. Service
by Ihis request. En r remark in this space and on the back of the white copy only.
ar� y���-
Calculate Inspection Fee - This Inspection Requesi will not be accepted wi�hout 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 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ON�Y TOTA��
Sign/Oudine Ltg. Xfmr. ,
Alarm/Remote Confrol
Swimming Pool
I here certi that I ins the eleclrical installation dexribed herein on the dates sfafed
Irripation Boom o....,.�.�_ .. .
Fee
Investigative Fe� ! � �����. =`- 1° �''`.
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 Al10NTHS.
OFFICE USE ONLY This request void 18 monfhs from validaHon date prinled in this box.
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* � 4 9 7 7 3 9 3� PLEASE PRINT OR TYPE �
R �O�/� /� Rough-in inspecfion required? ❑ Yes No Inspacfion Olher Thon RougMn: Ready Now ❑ Will Call
'� �I (You must call fhe inspecfor when ready� Dofe Ready:
I, �ensed confractor ❑ owner hereby request inspection of the above electrical work at:
Job Addreu Sh�x, or Rouae o.�� `/ Cily � �/ Zip Code
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Occ�pant �� � /�
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