P - 84503d�-�8-230
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REGIUEST FOR ELECTRICAL INSPECTION --» F.
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 ,
rcial In nal Farm
id. tg. Equip. Water Htr. Load Mgmt. Other:
ange Elec. Heat Temp. Service
ihe work covered y this request. Enter remarks in this space and on the back
Remod
copy only.
Calculate Inspection Fee - This Inspection Requesi will not be accepted without ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park $tall to 0 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S tlSE ONLY TAL
Sign/Oudine Ltg. Xfmr. � �
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins fhe eleclrical installafion described herein on fhe dales sfaied
Irrigation Boom Rough-In pa
Special Inspecti ^/% �
Final �
Investigative Fee �a1=� _
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFIC USE ONLY This request void 18 months 6om validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required? Yes ❑ No Inspeclion Other Than RougMn: ❑ Ready Now Will Call
3— _�� �You musf call fhe inspecfor when ready) Date Ready:
I, licensed confractor ❑ owner hereby request inspection of the above electrical work at:
lob Addreu (Sheet, Bo�c, or Roufe No.� City N � Zip Code
/7
Name or No. I Range No.
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ConhacforlCc
Mailing Address (Conhacbr or Owner
�c. c�►oo3ei
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Phone No.
License No.
No.
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Frl l 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
Only)