P - 80336,��89�-555 �
REQUEST FOR ELECTRICAL INSPECTION ¢
Minnesota State Board of Electricity � 3
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 ���.
(651) 642-0800 www.electricity.state.mn.us
Commercial Industrial Farm Remod Repair
Air Conditioner Hfg. Equip. Wafer Hfc Load Mgmf. Ofher.
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.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Ofher Insfallations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Lfg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL ��
Sign / Outline Ltg. Xfmr. p��.;,C.J
Swimming PooIG � Q (
I hereb certi that I ins ected the electrical installation described herein on fhe dates stated:
Irrigation Boom Rough-In Date � .
Special lnspection
Final Date � /. � ..
Investigative Fee —'�o
THIS INSTALLATION MAY BE ORDERED DISCONNECTfD IF NOT COMPLETED WITHIN 18 MONTHS_�
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion requiredZ ❑ Yes ❑ No Inspecfion Other Than Rough-In: eady Now � Will Call �
� "� .— �� You must call the inspector when ready Date Ready:
I, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfrcef, Box, or Roufe No.) Ciy Zip Code
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$ection No. Township Name or No. Range No. Fire No. nty A
Occu • Phone No.
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P wer Supplier Address
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E echica acfor / Company Name Conhacfor License No. Master Lic. No.
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Mailing Address (Conhador, Company or Owner Performing Insfa�lafion� �
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Aufhorized Siqnature I ontracfor, Company or Owner Performinp Insfallafio Phone Number
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2�1999 STATE BOARD COPV SEE �NSTRl1CT10NS ON 9ACK OF VELL[fW COPY