P - 81558REQUEST FOR ELECTRICAL INSPECTION
�� � O � � � � � � Minnesota State Board of Electricity
�. �i o 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
�� (651) 642-0800 www.electricity.state.mn.us "�'"
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusfrial Farm Remod Repair
Air Conditioner Htg. Equip. Wafer Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by this 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:
Ofher Installations Fee # Service Enirance Size Fee # Circuifs / 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 TO
Sign / Outline Ltg. XFmr.
Alarm/Remote Control
Swimming Po I
I hereb certi that I ins ected the elechical installation described herein on the dafes stated:
� -Irri9ation B Rough-In Date
Special Inspection
Investigative Fee F���� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 monihs from validation date prinfed in this box.
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�� PLEASE PRINT OR TYPE
Requesf te /�f Rough-in inspecfion required? ❑ Yes o (nspection Other Than Rou h- : eady o 'll Call
vYou must call fhe inspector when ready Dafe Ready:
I licensed contractor ❑ company ❑ owner hereby request i o t e el trica work at:
ob Address (Str , Bo , or Route No.�� � C' ip
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$ection o. Township Name or o. Range No: ire No. ounty
� Occupant
'���';�n����Y �tdS ELEC. INC.
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Address Cod(racror,"Com an Installation
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ed $ignhture,�Conha , fo o g I sf
� �i 2-�35-2000
1A-12 5/1999 STATF�y ARD COPY
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License No.
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY