P - 84597' REQUEST FOR ELECTRICAL INSPECTION -
��i O� 2 41 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Commercial
�X° OIJOV@
farm
Water Hh. Load Mgmt. pther:
Elec. Heat Temp. Service
request. Enier remarks in ihis space and on the back of
New
Remod
copy
Calculate Inspeciion Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entranc Si Fee # Circuits/Feeders Fee
Mobile Home Park Stall t 00 Am 0 to 100 Amps
Sfreet Ltg./Traific Sig. A ve 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT�L �„
Sign/Oudine Ltg. Xfmr. '�
Alarm/Remofe Control
Swimming Pool
I hereb certi Ifwt I ins the electricol installafion described herein on the dates sMted
Irrigation Boom RougMn �
$pecial Inspecfio —.Z ^ �
Final
Investigative fee �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFF7CE USE ONLY This request void 18 monihs from validation date printed in fhis box.
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* � 4 4 8 2 4� �* PLEASE PRINT OR TYPE
Requesf Date Rough-in inspecfion required? es ❑ No Inspecfion Other Than Rough-In: ❑ Ready Now i Call
�� �You must call ihe inspector when ready) Dafe Ready:
I, icensed contractor ❑ owner hereby request inspection of ihe above elecfrical work at:
lob Addreu (Sh f, Box, or Route No.) � Ci ' Zip Cade
� sT � ���o�e
Secfion No. Township Name or No. Range N. Fire No. Cou
�na i�l}
Occuppyl� Phone No.
Power Supplier
Moiling
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oc-�zsr�+ sr. w. Fc�TM.. ua� s6am4
� IConhacfor or O�ner Perfor ns ationl
or Owner
Mosfer Lic. No.
I
STATE BOARD COPY - SEE INSTRUCiIONS ON BACK OF YELLOW COPY