P - 82605� REQUEST FOR ELECTRICAL INSPECTION ��
fl �� ���(� Q Q � Minnesota State Board of Electricity
��� �•� ��•� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 �'
� (651) 642-0800 www.electricity.state.mn.us `���
"X" above the work covered by this request. Enter
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s in this space and on the back
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Installations Fee # Service Enirance Size Fee # Circ�its / Feeders F e
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. �0
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the elecfrical insfallation described herein on the dates stated:
IrfigatiOn Boom � �Rough-In. Date
Special Inspection �
Final Date
Investigative Fee - C '�Z �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monihs from validafion date printed in fhis box.
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PLEASE PRINT OR TYPE
Request afe Rough-in inspecfion required? ❑ Yes o Ins ection Other Than R u h-In: ad Now
P g y ❑ Will Call
You must call fhe inspecfor when ready Date Ready: �' oO
1, nsed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
JoiA�es� tleet, Box, or Route No.) � City • Zip Code
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Sedion No. Township Na� r No. Ranpe No. Fire No. Countv
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�al Contractor / Company Name �
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� A dress �Con}ractor, Company or Owner Performing
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ized Signafu e � ractor, Company or Owner P rfor
i�•� ' � � C./%Yr�� /.�
999 STATE BOARD COPY
Phone No.
.�s � �� - ��03
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Contractor License No. Master Lic. No. (Plant Elect. Only)
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Phone Number
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SEE INSTRUCTIONS ON BACK OF VELLOW COav