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P - 82263� REQUEST FOR ELECTRICAL INSPECTION �U - 9 6 9-� U o � Minnesota State Board of Electricity �_ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 551044993 (651) 642-0800 www.electricity.state.mn.us '��' on the back of the white copy only. . �,J � �I.L h,�-p l� . Calculate Inspection Fee - This Inspection Request will nof be accep►ed without the correct fee: Other Installations Fee # Service Enhance Size Fee # Circuits / Feeders Fee Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps Transformer/Generator INSPECTOR'S USE ONLY TOTAL O, Sign / Outline Ltg. Xfmr. • Alarm/Remote Control _............a . __. I hereb certi that I ins ted the elechical installaiion dexribed herein on the dates stated: Irrigation B Rough-In Dote Special Inspection Investigative Fee Final Dafe Z_ THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. OfFICE USE ONLY This requesf void 18 monfhs from validation dafe printed in this box. ��N�������I�����I�����I������������ � ao -� � 0 9 6 9 2 0 0 5 � `T�j � PLEASE PRINT OR TYPE Reque afe Rough-in inspection required8 ❑ Yes o Inspecfion Ofher Than Rough-In: dy ow � Will Call You musf call fhe inspector when ready Date Ready: Db I, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: I J b Address (Sheef, Box,.or No.) City • Zip Code b �.-�D', c� • �i- Section No. Township Name or No. Range No. fire No. Couny Occupa � � ���� �� Phone N�� � ^ I � � � Power Supplier � � (��� � / X Elecfric Contracfor / Company Name � � � � Mailing Ad ess (Confractor, Co ny or pwner PerForming a� � Authorized Si na re( onfrac r, Compny or Owner Pe rrt �� EB-00001A-12 5/1999 STATE BOAR COPY Licenpe No. � Masfer Lic. No. � � 1�� 4� l�l �'�Da� � SEE INSTRUCTIONS ON BACK OF YELLOW COPY