P - 81047REQUEST FOR ELECTRICAL WSPECTION ��
�1� 220 � �
e Minnesota State Board of Electricity
. 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
: Phone(612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industria! Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other.
Dryer Range Elec. Heat Temp. Service
"X" above (h� work covers�l by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate lnspectron Fee - Thrs lnspectron R uesi ilI not be accepted w�thout th rrect f:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Stree� Lrg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAY�j� �
Sign/Oudine Ltg. Xfmr. G��•
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins the elechical installation described herein on the dates staled
Irrigation Boom RougMn Dare
Speciallnspect ""
Final - . Dafe �V.
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 AAONTHS.
OFFlCE USE ONLY This requesf void 18 months from validation dafe printed in this box.
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PLEASE PRINT OR TYPE
Request Dafe �yJ��_ � Rou h-i� ins ion r uued?
Y g pecf' eq ' ❑ Yes o Inspecfion O�er Than RougMn: Ready Now ❑ Will Call
(You musf call the inspector when ready) Dafe Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Jo�d�es; Sfreet, x, or ou No.� � Ciry �j � Zip Code
ll , � e �
Secfion No. Township Name or No. Range No. Fire No. unty
Occupanf
POWCf SUDD�1@f I
� rna�i��9
IPhone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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