P - 82974� REQUEST FOR ELECTRICAI. INSPECTION
4 5 7� aJ �'t 0 Minnesota State Board of Electricity
� 1821 Uni��ersity Ave., Rm. S-128, St. Paul, MN 55f04
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Hfr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by ihis request. Enter remarks 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 'ze Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 ro 0 Amps ,� /v 0 to 100 Amps .7 0�
Street Ltg./Traffic Sia. Above 200 Am s Above 100 Amps
Transformer/Generator iNSrecroR'S USE ONLY /� TOTAL �
Sign/Oudine Ltg. Xfmr. -"����/Q,c.�,,�`�'�¢� � i�
Alarm/Remote Control �y��} � � �
Swimming Pool
I hereb certi thaf I in the elech ical installafwn described herein on the dates stated
Irrigation Boom RougMn Dare
Special inspecti
F��al � �re�
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE U� OPILY TMis request void ths from validation date printed in this box.
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* � 4 5 7 9 6 4 5* PLEASE PRINT OR TYPE
Requesf RougMin inspecfion required8 ❑ Yes ❑ No Inspedion Olher Than RougMn: ❑ Ready Now ❑ WiA Call
,3 �� � (You must call the i�spector when ready) Qale Ready:
I, �licensed conhactor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address (Sfreef, Box, or Route No.) Ciy Zip C�e
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Occupant
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Phone No.
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ATE BOAR - SEE INSTRUC710NS ON BACK OF YELLOW COPY