P - 80345REQUEST FOR ELECTRICAL INSPECTION �
V r`� V.J �- 3 2 5� Minnesota State Board of Electricity _ ':a
� 1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
�, (651) 642-0800 www.electricity.state.mn.us
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"X" above the work covered by this request. Enier remarks in this space and on the back of thQ rvhite copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Insta!lotions Fee # Service Enhartce Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / TrafFic $ig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �-�
Sign / Outline Ltg. Xfmr. —
Alarm/Remote Control
Swimming Pool
I herebvi certifv that I insoected the elechical ins�allation described herein on the dates stated:
' ' Final I Date)( � I
Irnestigative Fee �•r^ ^
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLV This request void 18 months (rom validaHon date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required$ ❑ Yes ❑ No Inspection Ofher Than Rough-In: Ready Now ❑ Will Call
�' —. �.' ti�� Q You must call the inspecfor when ready Date Ready:
l, licensedfpntractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
No. I Townshio Name or
C
!/12.0 �
Phone No.
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Confrac}or / Company Name . Conhactor License No. Mosfer Lic. No.
� i �I. �� �' 1-e�.c�-� i L C�4--z� la�
�ddreu (Contracfor, Company or Owner Perform� g Installafion) .
Signafure (Contracfor,
STATE BOARD COPY � SEE INSTRl1CT10NS ON BACK OF YELLOW COPV