P - 80371U�=899-383 �
REQUEST FOR ELECTRICAL INSPECTION -
Minnesota State Board of Electricity 3
1821 University Avenue Suite 5-128, Saint Paul, Mi�nesota 55104-2993 -
(651) 642-0800 www.electricity.state.mn.us "�'
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
�aW� �c..c,_4�t�lc.,S -%v- CQlol� �'� �j .
��c� --Fv� C-(,-fi t�r� C�n�ec� or>
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Ofher Installafions Fee # Service EnKance 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 ��
Sign / Outline Ltg. Xfmr. p2 5-��
Alarm/Remote Control
Swimming Pool
I hereb certi that I ios ted the electr �1 e bed herein on the dates sMted:
Irrigation Boom RougMn " Dare
Special Inspection
Final � � Date � \
Investigative Fee ` Z_� �
__ THIS INSTALLATION_MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 7 8 monlhs from validafion dafe prinfed in fhis box.
_II� i�l�� 5,�� • ,
UNI i II���fll��lli��fl�fl � �.�, .
* 0 8 9 9 3 8 3 4* � � t� E� � ��� �j
PLEASE PRINT OR TYPE
Request Date Rough-in insQection required? ❑ Yes ❑ No lnspection Other Than RougMn: Ready Now 0 Will Call
3� ,� O� You must call }he inspecfor when ready Dafe Ready:
j, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Streef, Box, or Roufe No.� Cify �� Zip Code
r^
� 1 � � 'b` � Y �
Secfion o. Township Name or No. Range No. Fire No. n �1
%33� � -t?,fl; �/,. ,, Ic,.
Power Supplier �
i�J J
Elecfrical Confractor / Company Name
�
Mailing Address (ConfrQcfor, Company or Owner
. .. _ n . . .. _ �.
, c,ompany or
n
Phone No.
Master Lic. No. (Plant Elect.
I�✓'I 1 1(� — IVdC J I
STATE BOARD COPV _ —+-' - —�-" �•^ "'• ^'°° -- — - _------