P - 82538fr '��"" "/ V�r ����REQUEST FOR ELECTRICAL INSPECTION �a°'E
U � � � �� � � � � Minnes�ta State Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 ���'
� � (651) 642-0800 www.electricity.state.mn.us �;i�.�:�a`�
281 p1
Calculate Inspection Fee - This Inspection Request will nof be accepted withoui the correct fee:
Other Installations Fee # Service En}rance 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 T
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the elecirical installation described herein on Ihe dafes stated:
Irrigation Boom Rough-In Dore
Special Inspection
Investigative Fee Final pa�eo �6`a�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monihs from validafion date printed in fhis box.
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PLEASE PRINT OR TYPE
Request�te Rough-in inspecfion required? ❑ Yes No Inspection Ofher Than Rough-In: Ready Now ❑ Will Call
Ia— � You must call fhe inspector when ready Dote Reody:
I,�licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
. Jo � c�dr�s `Sfre�t, Box, or Rou^e No.� � � 0 , � City � � � Zig Cosle , , _ ,
Section No. Township Name or No.
Occupant �
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Power Supplier
Ele�l ntractor / Company Name �
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� ili�c(dre� (Contra r, Con y or O
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Authori�qd Signature (Co�tractor, Copapqny or O�
99g STATE BOARD COPY
Range No.
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�ing Installation�
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o. Masf Lic. No. (Plan�ct. Onl �
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Phone Number
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY