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REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
4821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
. Other: New Addn
Commercial Industrial Farm Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ►he work covered by this request. Enter remarks in this space and on the back of the whiie copy only.
Calculate Inspection Fee - This Inspec►ion Request will not be accepted wifhout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stal) 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generafor INSPECTOR'S USE ONLY TOTAL
$ign/Oudine Ltg. Xfmr. �� ��
Alarm/Remote Conkol
Swimming Pool
I hereb certi ihaf I ins cted the elec}rical installafion described herein on the dates stated
Irrigafion Boom Rough-In Dare
$P2Cia� �f15pC � Final
Investigative ��`---""--�----�^ �- 7 e:. �' �
_ THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFflCE USE ONLY This requesl void 18 monfhs from validafion dafe prinfed in fhis box.
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* O i% 9 9 7 4��Ic PLEASE PRINT OR TYPE
Request Dafe Rou h-in ins tion r uired?
g pec eq ❑ Yes No Inspection Olher Than Rough-In: Ready Now ❑ Will Call
� j` �� (You must call the inspecfor when ready� Dafe Ready: ��.� 3� ��
I, �licensed conhactor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.� Ciy Zip Code
02�� -G/s?� ve n�E �r-��/�.�
Seclion No. Township Name or No. Range No. Fire No. County
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��pa^� Phone No.
SG►-r ;�o �c�
Power Supplier Address
Elechical Conhactor (Compony Name) Conhactor License No. Master Lic. No. (Piant Elect. Only�
�Ts,�C�� / � C�o/� �
Mailing Address �Conhactor or Owner Performing Installafion�
.�ia� �.s�-��- u� �`w �, ��- _ yr►� . s..s.�p�"
thorized $ignafure (Conhacfor or 9rr�er Performing Insfallation) Phone No.
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