P - 826971
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REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, Si. Paul, MN 55104 �
Phone (612) 642-0800 ""�'
Farm
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back
Calculate Inspection Fee - This Inspection Request will not be accepted without ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits
Mobile Home Park Stall 0 to 00 Amp 0 to 100 A
StreeYLtg./Traffic Sig. Abo 200 Am s Above 100
Transformer/Generator INSPECTOR'S USE ONLY
New
Remod
copy only.
Fee
Sign/Oudine Ltg. Xfmr. �
Alarm/Remote Confrol
Swimming Pool �%�-"�
I h ceAi tlat I ins the eleclrical installation described herein o tes s
Irrigation Boom RougMn �
Special Inspectio �� 23 ��
Final �--� G
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation date printed in this box.
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III II I II Iii II III Ir IfPI'01 II iII II III I IIII
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* O 4 O O°I L 3 U* pLEASE PRINT OR TYPE
Request Dale Rou h-in ins ion r uired$ Yes
g pecY eq ❑ No Inspeclion Other Than RougMn: ❑ Ready Now �II Call
1a� a3 ��� �You must call the inspector when ready) Date Ready:
I, licensed contracror ❑ owner hereby request inspection of the above elecfrical work at:
Mb Address (Snee�, eoX, or Roure No.� G Z�p Code
1 5 " �.�t . '
Secfion No. Township Name or No. Range No. Fire No. Couny �
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(Conhaclor or Owner
or
aECTIMC�
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Phone No.
�o. AAasfer Lic.�
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Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW fAPY