P - 81901u�-g��-660 0
Farm
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity �� 3
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ±�� 9
(651) 642-0800 www.electricity.state.mn.us
Ofher: New Addn
Dryer I I Range I I Elec. Heai I I Ti
"X" above the work covered by this request. Enter
�"�b� // ��T
�'�-�,f�
Calculate Inspection Fee - This Inspection
Other Installations Fee # Service Enhan
Mgmt.
rl�s in this space and on the back of ihe white copy
%�li D�i �it+/O� ��
will not be accepted without the correct fee:
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Am s
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
TransFormer/Generator INSPECTOR'S USE ONLY TOTAL �
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the elechical installation described herein on the dates stated:
Irrigation Boom Rougha� Da�e
Special Inspec �
Final Da
Investigative Fee � �
THIS INSTALLATION MAY BE ORDERED DIS IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE U�E ONLY This requesf void 18 months from validation date printed in this box.
I IIII�I) III II I�� II I�I �) III II II� � �
i�u �� i�l �.� •
* 0 9 2 1 6 6 0 7* ��,��
PLEASE PRINT R PE
Request Date Rough-in inspection required? �❑ Yes o Inspection Ofher Thon Rough-In: Ready N ' Call
�� You must call the inspector when ready Dafe Ready: �
I„�.licensed contractor ❑ company ❑ owner hereby request inspectio� of the above electrical work at: