P - 82168REQUEST FOR ELECTRICAL INSPECTION ���
Minnesota State Board of Electricity �'
�-�- 5 2- 6 0 2�I 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55704-2993
+" (651) 642-0800 www.electricity.state.mn.us "�'�
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Condi' Htg. Equip. Water Hir. Load Mgmt. Other:
Dryer Ronge Elec. Heat Temp. $ervice
"X" above`e work covered by this request. Enter remarks in this space and on the back of the white copy only.
1rt�C/L�- .�'1C; /'�� �C �
Cakulate lnspection Fee - This lnspection Request will noi be occepted without the correct fee:
Other Installations Fce # Service Entrance Size Fee # Circuits / Feeders fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg. / Traffic Sig. Above 200 Amps Above i QO Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTC ��
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the elechical i�stallation described herein on the dates stafed:
Irri9ation Boom RougMn �a�
Special Inspe
Final - Da �� .` �v
InvesTigative ee -
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
! � `� � OFFICE USE ONLY This requesf void 18 monfhs 6om validation dafe printed in this box.
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* 0 9 5 2 6 0 2 1* �l�
PLEASE PRINT R TYPE
. Request D Rough-in inspecfion required? ❑ Yes o Inspection Other Than R�h- n: ad Now ❑ Will Call
You must call }he inspecfor when ready Dafe Ready:
1, ' nsed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
J Ad�s (Sfreef, Box, or Route No.�� City, � Zip Code
�
SeMion No. Township Name or No. Range No. Fire No. County
Occu nf � ' Phone No
n � Q� - ba
Power Supplier Address
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Elecf ' ntractor / Company Na e . � .� Confractor License No. Master Lic. No. (Planf EIeCt. Only�
W' � �C�—
Maili g Add es (Contmcf Co ny or Owner Per
n 1�°��h�
Authorized S'�re (Confracro , ompany or Owne
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EB-00007A-12 5/1999 STATE BOARD
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P one Number �
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY