P - 81232REQUEST FOR ELECTRICAL INSPECTION ��
U� 8 6 6� 13 7� Minnesota State Board of Electricity 3
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 ���
(651) 642-0800 www electricity state mn.us '' '
Dryer
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Duplex Apt. Bldg. Other: New Addn
Industrial Farm � Remoti Repair
Htg. Equip. Water Htr. Load Mgmt. Other:
Ra�ge Elec. Heat Temp. Service
�rk covered by this request. Enter remarks in this space and on ihe back of the white copy only.
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Calculate Inspeciion Fee - This Inspec►ion Requesi will not be
Ofher Installations Fee # Service Entrance Size fee
Mobile Home Park Stall 0 to 200 Amps
Street Ltg. / Traffic Sig. Above 200 Amps
Transformer/Generator INSPECTOR'S USE ONLY
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins fed the elecfrical i
Irrigation Boom Rough-In
C.,o��.,l I�<.,e�+�., � ..
ap►ed without the correct fee:
# Circuits / Feeders
0 to 100 Amps
Above 100 Amps
TOTAL
described herein on the dates
Date
I lnvestigative Fee � '; � � ��� ( � � � --(�/L
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1 ONTHS.
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OFFICE USE ON�Y This request void 18 months from validation date printed in this 6ox.
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PL�ASE PRINT OR TYPE
Request Date Rough-in inspection required$ ❑ Yes No Inspaction Other Than RougMn: ❑ Ready Now: Will Call
C`� �� - You must call fhe inspecbr when ready � � Dafe Ready: � . . �
I, licensed contractor � company ❑ owner hereby request in.speetion oF the above electricpl work at:
Job Address �St eet, Box, or Route Np.) � �- Ciy .// Zi�Code�
� � �� � �
Secfion No. Township Name or No. � Range No. Fire No. Counfy _ �_ � �
Occupant
Power
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�ompany rvame
p�Ad�lE 4iTG. A,C EL�CT,, ��`�
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STATE BOARD COPY
Phone No.
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License No.
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.16 � (��a�7s�-(o2�-0 �
SEE INSTRUCTIONS ON BACK OF YELLOW COPY