P - 84002, 5,.� J-371 �
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RE(�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity '3
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800 "�'
New
Commercial I dustrial Farm rcemod, Ke ai
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. 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.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correc± fee:
Other 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. �S�J�1
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the electrical installation described herein on the dates stated
Irrigation Boom Rough-In ��
Special Inspec r"
Final d _ Date� // p�
Imestigative Fe �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USF ONLY This requesf void 18 months from vaiidafion dafe prinfed in this box.
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* O S 5 O 3 7 L°J * PLEASE PRINT OR TYPE `��� �/
Request Daf� /y Rough-in inspection required? ❑ Yes No Inspection Olher Than RougMn: Recdy Now ❑ Will Call
C`��L' �7 (You must call ihe inspector when ready� Date Ready:
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I, ' licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sfreef, Box, or R� No.) � � City � Zip Code
�:�� �� ' i Q L�(�� � ~���f�'��
Section No. Township Name or No. � Range No. Fire No. Couny
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Occupant Phone Na . �'''y �
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F�������m�,��,�Ft r i c, I n c.
lailing Address (Conhactor or Owner Performing Insfallafion)
25,� Neva.da A�n�ye Nort
/
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Master Lic. No.
301 Golden Valle 55427
Phone No.
� �� 5�44-3300
3UCTIONS ON BACK OF YELLOW COPY
Only)