P - 82592REQUEST FOR ELECTRICAL INSPECTION °`E
1���'] � Minnesota State Board of Electricity �� `3
J 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 �_�, ,��
(651) 642-0800 www.electricity.state.mn.us "�?�
"X" above the work covered by
Calculate Inspection Fee - This Inspection Request will not be accepted without fhe correct fee:
Other Installations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 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. f,� � 5� ��
Alarm/Remote Control �� 6
Swimming Pool
I hereb cerfi that I ins ected the elechical installation described herein on the dates sfaied:
Irrigation Boom Rough-In � � Dare
S�ecial Insseclion � °"O�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLV This request void 1 8 months from validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Date Rou h-in ins ection re vired? es p g ❑ Ready Now Will Call
g p q ❑ No Ins ection Ofher Than Rou h-In:
You musf call the inspector whe ready Date Ready:
1, �,,licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo�d�s�flet, Box, or Rout�.) �� City Zip Code
�n.r ' � Y� � �e
Secfion No. Township Name or No. Range No. Fire No. Couny �
Occupant \ Phone No.
es` � � S �S'1—vZ�-
Power Supplie Address
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Electrical Contractor / Company Name Contrador License No. Master Lic. No. (Planf Elecf. Onl;
Prizm Electric, Inc. , CA02765
Mailing Address (Contractor, Company or Owner Performing Insfallafion)
6361 Sunfish Lake Court, Ste. 300, Ramsey, MN 55303
Au�horized ' nature (Confractor, Company qr�Qw�.ter Performing Installation) Phone Number
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5�1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY