P - 82425(�����-309 �
REQUEST FOR ELECTRICAL INSPECTION =
Minnesota State Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Condifioner Hig. Equip. Water Hfr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesi. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Requesi will not be accepfed wiihout the correct fee:
Other Installafions Fce # Service Enh nce Siz Fee # Circuits / Feeders fee
Mobile Home Park Stall 0 0 200 mps ` 0 to 100 Amps
Street Ltg. J Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA ;_]'1
Sign / Outline Ltg. Xfmr. � VV
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ed rhe elechical installation described herein on the dates stated:
Irri ation Bo �' ^
9 Rough-In Dafe
Speciallnspection �
Final Dat r q j ,��
Investigative Fee �-�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ON4Y This request void 18 months from validafion date printed in lhis box,
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PLEASE PRINT OR TYPE
R f D � Rough-in inspecfion raquired$ ❑ Yes ❑ No Inspecfion Ofher Than RougMn: ❑ Ready Now ill Call
� You must call the inspector when ready Date Ready:
1,�1icensed contractor ❑ compony ❑ owner hereby request inspection of the above electrical work at:
Jo Ad ress eet, Bo , r Route o.) Zip Code
r,' e
Section N. Township ame or No. ange No. Fire No. Coun
Occupant Phone No.
10981 4TH ST. NE
Address (Contractor, Com any or Owner Perfor
IANOVER MI� 55341
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BOARD COPY
Master Lic. No.
I Vf�i'�-JO'%d-rlJ I
SEE INSTRUCTIONS ON BACK OF YELLOW COPY