P - 81702, REQUEST FOR ELECTRICAL INSPECTION
U������� p � Minnesota State Board of Electricity
�� 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
> (651) 642-0800 www.electriciry.state.mn.us " '
Home Duplex Apf. Bldg. Other: New Addn
Commercial Indusirial Farm Remod Repair
Air Co ' r ' Hig. Equip. Waier Htr. Load Mgmt. Ofher:
Dryer Range Elec. Heaf Temp. $ervice
"X" above the work covered by this reqvest. Ent�r remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepied without the correct fee:
Other Installafions Fee # Service Entrance Size Fee # Circuifs / 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 TOTA p� �
Sign / Outline Ltg. Xfmr. �'
Alarm/Remote Control
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I hereb certi that I ins led the elecfrical installafion described herein on fhe dates sfated:
Irrigation Boom Rough-In Dare
Special Inspection
Final . j Date �
Investigative F �- G� G� 3
� THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validation daie printed in fhis box.
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PLEASE PRINT OR TYPE
Request D Rough-in inspecfion required? ❑ Yes No Inspecfion Other Than Rough-In: ead Now � Will Call
���/ �� You must call fhe inspector when ready Date`�Ready: ��-'i kf� �� �,
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1, �Ijcensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Add� s(5t�, Box, q Rou� o. Giry � Zip Code �
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ection No. Township Name or No. Range No. Fire No. Coun
/-59��7
,� ,7 Conhacror
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�ner Perfor ing I stallafion� �/�/J J//�
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or ner Performina Insfallationl
EB-0000�'4-�2 5/�999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY