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
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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.
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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.
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�c� L�zcc �—
-acfor, Company or Owner Performing Installation�
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No.
Master Lic. No.
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Phone Number