P - 816160
-� _!1-� 8_-7i1 [� � f REQUEST FOR ELECTRICAL INSPECTION �` °�
v r�r:� Minnesota State Board of Electriciry ti- o �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 _ -
(651) 642-0800 www.e/ectriciry.state.mn.us
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htc Load Mgmt. Other:
Dryer Range Elect. Heat Temp. Service
X" above the work covered by this requesf. Enter remarks in this space and on the back of the white copy only.
Ca/cu/ate lnspecti�
�ther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote BnrrtfoF�
Fee - This Inspection Request will noi be accepted without the correct fee.
ae # Service Entrance Size Fee # Cirouits / Feeders
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL
� ! hereby certi that 1 inspecied the elecUical installation described herein on the dates stated:
Irrigation Boom Rough In Date
� Special Inspection >�"::��
Investigative Fee �M1°� ' oate _��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS._ �
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� �I �IIII IIIII ��I�� IIII� �I�I) � ��� ��I OFFICE USE OIIrLY This request void 18 months from validation date printed in this box.
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l � PlEASE PRINT OR TYPE
Request Date l �
�. � �; , Rough-In inspection required? ❑ Yes � Na Inspection Other Than Rough'-In: ❑ Ready Now�l Will Call '
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You must call #he inspector when ready! Date Ready: ,,_ ; u..,
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I, ❑ licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street Box or Route No.) City Zip Code
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Section No. Township Name or No. Range No. Fire No. County
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Phone No. ,. _
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Po��.,^y�pplrer � ; Address � �_
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EleGtncal Contractor / Compan� M1leme_ , Contractor �.icense Na, - Master Lic. No. (PIaM Elect. Only)
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Mailing Address (Contractor, Company or Owner Performin� Installation) R �� I
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Aut gnature (Contractor, Company or Owner Performing Installation) Phone Number
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B-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY