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P - 82613� U'=909-731 � REQUEST FOR ELECTRICAL INSPECTION '�� Minnesota State Board of Electricity �^ �; 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 Industrial Farm Remod Repair Air Conditioner Htg. Equip. Water Htr. Loa Dryer Range Elec. Heat Tert "X" above he work covered by this request. Enter re ���!^/L � ./�� ��� t'.�^ Mgmt. Other: Service arks 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: Other Insfallations Fee # Service Entrance 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 TOTAL /� �%� Sign / Outline Ltg. Xfmr. �V • �`� Alarm/Remote Control Swimming Pool I hereb certi that I ins ecfed ihe electrical in tallation described herein on the dates sfated: Irrigation Boom Rough-In � Da� Special Inspectio ' "����� Fiwfll^ Dat Investigative Fee � — � '—� � THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. OFFICE USE ONLY This requesf void 18 months from validation date printed in fhis box. Illllllllllllllllilllll�llllllll�ii�lllllllllllll • ��-5� * 0 9 0 9 7 3 1 2 * �3�3 PLEASE PRINT OR TYPE Request Date Rou h-in ins ection re uired? Yes p g ❑ Ready Now �,Idfl�Call 9 p q ❑ No Ins ecfion Other Than Rou h-In: �� i You must call the inspecfor when ready Date Ready: I,�licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: Job Addr�ss �Street, Box, or Route No.� _ -� Cify , Zip Code I Power or Range No. � Fire Company Na� �r� `��� re;� Confracfor License No. �� �yry , � � C � / /��j // �c� L�zcc �— -acfor, Company or Owner Performing Installation� /�i�✓ /1. / � No. Master Lic. No. /� Phone Number