P - 82567r REQUEST FOR ELECTRICAL INSPECTION �`�=E'
� � -o� 4-548 DO �
Minnesota State Board of Electricity `
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us ��
„ Home Duplex Apt. Bidg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elect. Heat Temp. Service
'X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
N�P �AVER'S �WITCH
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee.
Other Installations Fee # Service Entrance 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 TOTAL
Sign / Outline Ltg. Xfmr. �•�
Alarm/Remote Control
Swimming Pool
I hereby certiy that I inspected the electrical installation described herein on the dates stated:
Irrigation Boom Rough In Date
Special Inspection
Final ` 6/
Investigative Fee -
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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. .� �� ��---� �-�--�--�----.---..� ..............�.".1..�..�.y...u.,j.l•u•OFFICE USE ONLV This request void 18 months from validation date printed in this box.
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PLEASE'PRI� �t�f �
Request Date Rou h-In ins ection re uired? ❑ Yes ❑ Nd� Ins ection Other Than Rou h-In:
g p q p g L�Ready Now ❑ Will Call
6....� A�l�W1 You must call the inspector when ready! Date Ready:
I, j�licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code:
Section No. Township Name or No. Range No. Fire No. County
------ --- --------------------- - AN�KA
Occupant Phone No.
Si.HLANGEN AL'JIN W
Power Supplier Address
NSP
Electrical Contractor / Company Name Contractor License No. Master Lic. No. (Plant Elect. Only)
Mailing Address (Contractor, Company or Owner Pertorming Ins[allation)
'?3+.�'J TERRITORIAL RQP.D �P.II�1T PA�!L Mh! +55114
Authorized Signature (Contractor, Company or Owner Performing Installation) Phone Number
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EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY