P - 82119"` REQUEST FOR ELECTRICAL INSPECTION �
� �� Q S%��/� 0 � Minnesota State Board of Electricity
lJ J � �t 7g21 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us
"X" above ihe work covered by this request. Ente r marks in this space an on i ack t e white cop only.
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� C.�a,��crn � � `-� $4 �
Calculate Inspection Fee - This Inspection Request will not be accepted withoui ihe correci fee:
Other Insfallations Fee # Service ntrance Size Fee # Circuiis / Feeders Fee
Mobile Home Park Stall 0 to 0 Amps 0 to 100 Amps(1,60
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA ���
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool I hereb certi that I ins ted fhe elechical installation described herein on the dn%s sta��" G�
Irrigation Boom Rough-In Date
Special Insp o � � �,o-�
Final t . ��,�
Investigative Fee %
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFflCE USE ONLY This request void 18 months from validation date printed in this box.
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* 0 9 1 7 6 4 0 �� o�� J�.3
PLEASE PRINT OR TYPE
Request Dafe Rough-in inspecfion required$ ❑ Yes No Inspecfion Other Than Rougfrin: ❑ Ready Now ill Call
��� You must call the inspecfor when ready Date Ready:
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job ddress �Street, Box, or Rou e No.) Ciry � Zip �, f��
� �� ^ l./L � l 1
Secfion No. Township Name or No. Range No. Fire No. County � �n _
License No.
Mailing Address�Co� �Performing Insfallation�
m
I Authorized Nre (Co actor, pany or Owr�r Performing In to afionj I Phone Nu� �
� ?-�p�_D
EB-OOOOlA-1 5/1999 STATE BOARD COPY SEE INSTRl1CTIONS AN BACK �F YELLAW COPV