P - 80369U=�9�-385 �
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REQUEST FOR ELECTRICAL INSPECTION
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 '���
Home I �Duplex I IApt. Bldg. IOther: New Addn
Commercial Industrial Farm Remod Repair
I I Dryer I I Range I I Elec. Heat I I Temp. Service I
"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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Caicula►e in pection Fee - This Inspection Request will nof be accepied without ihe correct fee:
Other Installations Fee # Service Enlrance 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
TransformerjGeneraror WSPECTOR'S USE ONLY TOTAL� �
Sign / Outline Lig. Xfmr.
S �-
Alarm/Remote Control
Swimming Pool `
I hereb certi thaf I ins ted the elechicol insfallallon described herein on fhe dafes sfafed:
Irrigation Boom Rough-In , ►+J Dare
Special Inspection
Investigative Fee Final Date-t, Z-�'�-�
✓
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 monlhs (rom validation date printed in fhis box.
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0 8 9 9 3� 5 9*
�E�� f�l�lj OR TYPE
Requesf Date Rough-in inspecfion required$ ❑ Yes ❑ No Inspecfion Ofher Than Rough-In: Ready Now ❑ Will Call
.� �. f b�, 0� You must call the inspector when ready Date Ready:
1, licensed coniractor ❑ company ❑ owner hereby request inspection of the above elechical work at:
Job Address (Shcet, Box, or t� N.) C� � Zip Code
$w W Gl V t �
Secfion No. Township Name or No. No. Fire No. Co
,�,� � ��
Occupont _
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Power Supplier � Address
EI frical Contractw f Company Name , Conhactor License
Mailing Address (Contractor, Company or Owner Pedorming Installafion�
l� c� (�.
Authorized Signatore (Contractor, Company or Qwoer Performing Installation) �
E 1A-12 5/1999 STATE BOARD COPY
Phone
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SEE INSTRl1CT10NS ON HACK OF VELLOW CAPV�