P - 84172� J
� 525--987 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board oi Electricity �
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 ���
'� Home Duplex Apt. Bldg. Other:
Commercial Industrial Farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the wor cqvered by this request. Enter remarks in t's space a on the bac
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Calculate Inspection Fee - This Inspection Request will not be accepted wiihout the correct fee:
Other Fee # Servi e Entranc ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps S' 0 to 100 Amps
Street Lfg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S uSE oN�v TOT}�L r--.f�
Sign/Outline Ltg. Xfmr. 3U �`JU
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins fed ihe elechical insfallation described herein on the dates stated
Irrigation Boom RougMn pa�
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$pecial Inspectio
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Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months 6om validation date prinMd in this box.
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Request Date � Rough-in inspection required? ���yyy Yes
`�� , q� ❑ No Inspecfion Other Than Rough-In: ❑ Ready Now ❑ Wiil Call
�,��" /� � (You musf call the inspector when �eady� Date Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.) Ciy ,�� Zip Code
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Section No. Township Name or No. Range No. Fire No. �Qouny '�
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Occupanl�• � � � Phone No.
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Power`Sup ie� ^
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BOARD
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C�hacfor License No.
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'S848
Lic. No.