P - 81595' REQUEST FOR ELECTRICAL INSPECTION �� _
(1 �� p�� 7�� � Minnesota State Board of Electricity �
lj U 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 ��
(651) 642-0800 www.electricity.state.mn.us `'�
"X" above the work covered by this r��er remarks in this space and on the back ot �he whife c
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Calculate Inspection fee - This Inspection Request will not be accepted without the correct fee:
Other Insfallations fee # Service Enfrance Size Fee # Circuits / Feeders
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. G
Alarm/Remote Confrol
Swimming Pool
I hereb certi that I ins ted the electrical installation described herein on the dates stated:
Irrigation Boo Rough-In �o�
Special Inspection
Final ��e�
Investigative Fee `��'-
THIS INSTALLATION MAY BE ORDERED DISC NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 1 S months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Rough-in inspecfion requiredZ ❑ Yes o Inspection Other Than Rough-In: ❑ Ready Now Will Call
�� a`� You must call ihe inspecror when ready Date Reody:
I, icensed contract ❑ ompany ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, No.) Ciy � Zip Code
.�Sf�- ��. �(r�' '�� �c�� 5 S' 3 s�
or No. — � Ranpe No. � Fire No.
Occupant Phone No.
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Power Suoolier Add�ess
Mailing Addi
E�ECT. ;i•i+:. I - -�� f� 6
AVE. N.C:.
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Master Lic. No.
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY