P - 80243J����.-250 �
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity
1821 University Avenue Suite S-126, Saint Paul, Minnesota 55104-2993 �����
(651) 642-0800 www.electricity.state.mn.us
Other: New Addn
Commercial Industrial Farm
Air � ioner tg. Equip. Water Htr. Load Mgmf.
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in t�
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space and on the back of the white copy
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Installations Fee # Service Entrance Size Fee # Circuits / Feeders
Mobile Home Park Stall 0 to 200 Amps a 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TO^T�AL
Sign / Outline Ltg. Xfmr. d�.
Alarm/Remote Control
Swimming Pool
Irriqation Boom _ _ _ _ _
installation described herein on the dates stated:
' ' Final � �. � . Dafe/'}T �//J ,� C�
Investigative Fee ����.� � / �-' ����
THIS INSTALLATION MAY BE ORDEREp DISC TED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinfed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Date Rough-in inspection requiredZ ❑ Yes �'I�o Inspection Other Than Rough-In: �RAady Now ❑ Will Call
�a a. 3_� 9 You must call the inspecror when ready Dote Reody: j�� a,N �G� cr
1, �'licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
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