P - 82652RE(�UEST FOR ELECTRICAL INSPECTION
/�(� (' ' Minnesota State Board of Electricity
`-E l�,�J� � 9 0 6 1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104 �
, Phone (612) 642-0800 `�'
Home Duplex Apt. Bldg. Other: ew Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
er �Range Elec. Heat Temp. Service
"X" above e work covere y this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 00 Amp 0 to 100 Amps
Street LTg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT,AL
Sign/Outline Ltg. Xfmr. �b 75
Alarm/Remote Control
Swimming Pool �/'
I hereb certi that I ins ected the electrical insfallation described herein on ihe � stafed7'
Irrigation Boom Rough-In �a�
Special Inspecti `f�" Z � 2' _ �6
� Final . � �a ,�
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 ONTHS.
— — – �
OFFlCE USE ONLY This request void 18 months from validation dafe prinfed in this box.
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I III) (I �II II �I� II ��I II II I I II III � �
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* � 4 � 0 9 0 6 4* PLEASE PRINT OR TYPE
Request Date Q / Rough-in inspection required? Yes ❑ No Inspecfion Other Than Rough-In: ❑ Ready Now ❑ Will Call
� Z�' � 1. 10 (You must call the inspector when ready� Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address (Sheet, Box, or Roufe No.) City Zip Code
02 CN-n�s7`.�'N So �7 U9�� �rt u��e�/
Section No. Township Name or No. Range No. Fire No. County
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Occupant
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Power Supplier � �
Phone No.
Elechical Confra � I Contractor License No. I Master Lic. No. (Plant Elect.
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Mailing Address (Contractor or Own�erformi�g Iry(allation)
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OP YELLOW COPY