P - 83384REQUEST FOR ELECTRICAL INSPECTION ��E
�j(� Minnesota State Board of Electricity �
6 91 �"� 1. � lJ � 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800 `'�
I/Il-lome Du�lex Aot. Blda. Other: New Addn
Commercial Industriai Farm
Air Cond. Htg. Equip. Water Htr
Dryer Range Elec. Heat
"X" above the work covered by this request. En
/Od ��,,o �
Remod
Load Mgmt. Other:
Temp. Service
narks in this space and on the back of the white copy only.
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
$treet lig./Traffic Sig. Above 200 Amps Above 100 Ai
Transformer/Generator INSPECTOR'S USE ONLY TOT,
Sign/Outline Ltg. Xfmr.
Alarm/Remote Confrol
�
Swimming Pool
I hereb certi that I ins ihe elechical installafion described herein on fhe dah
Irriaafion Boom o,,,,��,,,, n�r�
�
Fee
Special lnspect" � � °
Fi�al
Investigative Fe —1 --
THIS INSTALIATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFiCE USE ONLY This request void 18 months from validation dafe printed in this box.
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P EASE PRINT OR TYPE
��/� Rough-in inspecfion required$ ❑ Yes No Inspecfion Ofher Than Rough-In; Ready Now ❑ Will Call
�You must call fhe inspecfor when ready) Dafe Ready:
censed conhactor ❑ owner hereby request inspection of the above electrical work at:
r�cs15heet x, or Ro N Ciy • Zip Code
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Jo. Township Name or No. Range Na � Fire No. Co ty
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occopa�r
Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY