P - 81019REQUEST FOR ELECTRICAL INSPECTION °'E•°
U����� C'I C � Minnesota State Board of Electricity �'
. C� 1 V 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -
1 (651) 642-0800 www.electricity.state.mn.us '� �
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy
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Calculaie Inspection Fee - This I spe on Request will not be accepted wifhout 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
Sign / Outline Ltg. Xfmr.
Alarm/Remote Contro)
Swimming Pool
I hereb certi fhaf I ins ected the electrical installqfion desa
Irrigation Boom Rough-l�
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on the dates stated:
� imesngatrve ree — `T �� � ( ��c� � ,� � �� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFRCE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT R TYPE
Requesf Date /�. � Rough-in inspecfion required2 ❑ Yes ❑ No Inspecfion Ofher Than Rough-In: Ready Now ❑ Will Call
9 You must call the inspecfor when ready Date Ready:
I, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
J Address (Sfreet, Box, or Rou`te No.) . �/ c Ci Zip Code
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or
Occupant
Phone
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DEPENDABIE ELECTRIC, INC. ��j�7� �f �/%��
i� i r �fro �p�ar�yf�y.�n rming Insfallafion) ' � �
Coo� Rspids, MN 55433 �
ufhorized $ignature (Con}rador, Co or ner Performiny I � fi n� � � � Phone Number
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5�� 999 STATE RD OPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY