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"X" above the work
RE(�UEST FOR ELECTRICAL INSPECTION > �.
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Other. , New Addn
ustrial Farm
�. Equip. VVater Htr. L�
�g 1 Elec. Heat T�
�r y this request. Enter rem�
Mgmt. Other:
Service
in this space and on the back of ►he white copy only.
Calculate Inspeciion Fee - This Inspection Request will nof be accepfed wifhout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits
Mobile Home Park Stall to 00 Amps 0 to 100 A
$treet Ltg./Traffic Sig. Abo e 200 Am s Above 100
Transformer/Generator INSPEC70R'S USE ONLY
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Fee
�
I he�eb ceAi thaf I ins ted the electrical installation described herein on the dates stated
Irrigation Boom Rou h-in D re
Special Inspecti 9 —2 �s `
Investigative Fee F��al
�-�-1�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validaTion date prinfed in this box.
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* � 4 9 8 9 7 i 5* LEASE PRINT OR TYPE 7�'��
Request Date Rou h-in ins tion r uired?
��_ g pec eq s ❑ No �nspection Other Than RougV�ln: ❑ Ready Now Call
(You must call the inspector when ready� Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box or Roufe No.) � City Zip Code
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Section No. Township Name or No. Range No. Fire No. Coun ( � L_
Power
Electrical
,
Phone No.
)�f C-[�j�
�� � � Address
ro�r�'���t�yRIC� INC. CA00381 Connactor ticense No.
310G•22bT�1 ST. W.. FGTN., MN 55024
us (Cor�yacfor or Ownerserforminp s ion
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