P - 80233REQUEST FOR ELECTRICAL INSPECTION �
- (� � � � � � � � � � Minnesota State Board of Electricity
��°._
�� 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ����:
(651) 642-0800 www.electricity.state.mn.us `'�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner tg. Equip. Water Htr. Load Mgmf. Other:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted withou► the correct fee:
Other Insfallations Fee # Service Enhance 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 w f
Sign / Outline Ltg. Xfmr. � U
Ala�m/Remote Control
Swimming Pool
I hereb certi that I ins ected the electrical installation described herein on the dafes stoted:
Irri9ation Boom Rough-In Dote
$pecial Inspecti
final % Daf • F �d
Investigative Fee ' 'L.%~
THIS INSTALLATION MAY BE ORDERED DISC CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs kom validation date printed in this box.
lllll��lllllllllllllllll�lllll�l��1� • ao.�
* 0 9 � 9 2 1 3 1* ��`f
PLEASE PRINT OR TYPE
Requesf Dafe� Rough-in inspecfion required? ❑ Yes ❑ No Inspecfion O�er Than Rough-In: Ready Now ❑ Will Call
� "�j Q You must call the inspector when ready Date Ready:
, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreet, Box, or Rou No.� �� Ciy Zip Code
� �
Secfion No. Township Name or No. Range No. Fire No. Co�nty _ �
I Occupanf � � � ( Phone� �
.��u., �� � � ` o�
Power Supplier _ � „ ,� Ad ress
Conhacfor License
Cl'RIC. {NC.
s.� �N�„�5433,,..,,,,,,.y,,.,��,� 1�
Signature �C or, Company or ^Owner Perform%i g /Installation) Phone Number
! . \ \ / /C. �. _ .� i t'1 il �. r�i •..