P - 816051_�-1 �_750� � REQUEST FOR ELECTRICAL INSPECTION ,�` �`'
� � Minnesota State Board of Electricity oti;- '3
�. 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -__ _
(651) 642-0800 www.e/ectriciry.state.mn.us
Home Duplex Apt. Bidg. Other: New Addn
Commerciai Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. ` Load Mgmt. Other:
Dryer Range Elect. 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.
Ca/culate Inspection Fee - This Inspection Request will not be
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
TransformedGenerator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Qonirel r
O to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
�ted withoui the correct fee.
# Circuits / Feeders
0 to 100 Amps
Above 100 Amps
ITOTAL y ,
�., r r;
' I hereby certity that I inspected the electrica! installation described herein on the dates statetl:
Irrigation Boom Rougn in Date
" Special Inspection �' ` �" ` ta�
Investigative Fee �� � G � Z- �'' �
THIS INSTALLAT�ON MAY BE ORDERED ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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� i..,�� ����I IIII� II�II III �II �� � OFFICE USE ONLY This; quest void 18 months from valida6on date printed in this box.
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PLEASE PRINT OJ� TYPE
Req4eat Date. . 9 P eq �� Pe 9 fJY.sNqW:i��111 Call
, � Rou h-In ins ec[ion r uired? ❑ Yes � No Ins ction Other Than Rou h-In: � Rea
You must call the inspector when ready! Date Ready: ` �
I, ❑ licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job..f��(rgs,� (Street� BoX, RLFP.USe,N¢�,._ . City �-.i.-�; �{ �_.; Zip Codew
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Section No. Township Name or No. Range No. Fire No. Counry
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0�4upan? , Phone No. , _
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PoW@�:,�pplier � a J� C} Address _
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Electrical Contractor / Company Name Contractor License No. Master Lic. No. (Plant Elect. Onty)
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Mailing Address (Contractor, Company or Owner Pertorming Installation)
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' ature (Contractor, Company or Owner Performing Installation) Phone Number
EB-OOOOtA-12
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STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY