P - 81083REQUEST FOR ELECTRICAL INSPECTION ���
U�`8 9 5- 612 � Minnesota State Board of Electricity
1821 University Avenue Suite S-728, Saint Paul, Minneso[a 55704•2993
F
� (651) 642-0800 www.electricity.state.mn.us `��'"'��
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusirial Farm Remod Repair
Air Co ner Htg. Equip. Wafer Hfr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Senice
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
/ � � � C�ii�J �' �J
Calculafe lnspection Fee - This fnspection Req st rl! not be accepted witho�i the correct fee:
Ofher Installations Fee # Service Entrance Size Fee # Circuits / 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. • �
Alarm/Remote Control
Swimming Pool ``
I hereb certi that I ins cted the elechicol installation described herein on the dates stafed:
Irrigation Boom�' F n Roughdn Date
Special Inspec i n
Final �ar�
Investigative Fee G—� �a
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE U8E ONLY This request void 18 months from validation date printed in this box.
IlIII�I��(��1111lIII��(l�i�� 111��� i �°��
�
* 0 8 9 5 6\1 2 0* ���
PLEASE PRINT OR TYPE
. Request Date Rough•in inspection required2 ❑ Yes ❑ No Inspection Ofher Than Rough-In: Ready Now ❑ Will Call.
I��� You musf call fhe inspector when ready Date Ready:
, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
J Address (Sfreef, Box, or Rout No City Zip Code
� • � ��l
Section No. Township Name or No.� e No. Fire No. Coun
Q�
Occupanf - ... Phon�� � ��
Power Supplier _ Address
Elechical Con}wcror / Company Name Contractor License
DEPENOABLE ELECTRIC. Ii�C•
/����dd��nt�grp�p��r�wMr�rforming Install rj�- �;. � ��,
C�on Ra ida; MN 55433 �� V�' �
Aufhorized �Siqnature ICon}ract mpany or Owner PerformiM InsfallaKon� �
�► y �—)v�Ul
REF WSTRl1CT1[1N5 ON BACK OF YELLOW COPY