P - 78591� RE(�UEST FOR ELECTRICAL INSPECTION
��n (((]]] � � � � � Minnesota State Board of Electricity
�� � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
�C'c.�` (651) 642-0800 www.electricity.state.mn.us
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Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Cakulate Inspection Fee - This Inspection Requesf will not be accepted without the correct fee:
Other Installations fee # Servic ce Size Fee # Circuits / feeders F
Mobile Home Park Stall 0 200 A ps 0 to 100 Amps �
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA�L ��
Sign / Outline Ltg. Xfmr. '
Alarm/Remote ontrol
Swimming Poo ^ (�
1 hereb certi that I ins ected the elechical installation described herein on the dates stated:
Irrigation Boom RougMn �°� 2,$'—�i3
a2_
Special lnspection F�nal DO�e 3� 0
Investigative Fee ^
THIS INSTALLATION MAY BE ORDERED DIS ONNECTED IF NOT COMPLETED WITHIN ONTHS.
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OFFICE USE ONLY This request void 18 months from validation date printed in fhis box.
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PLEASE PRINT OR TYPE
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contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
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STATE BOARD COPY
SEE INSTRUCTIONS ON BACK OF YELLOW COPY