P - 84015551-558 �
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REQUEST FOR ELECTRICAL INSPECTION �»�
Minnesota State Board of Electricity
1821 Universiiy Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Other: New Addn
Commercial Industrial Farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
above the work covered by this requesi. Enter remarks in this space and on
Remod
the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted wiihout fhe correct fee:
Other Fee # Service Entrance 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 Am s
Transformer/Generator INSPECTOR'S USE ONLY TOT
Sign/Outline Ltg. Xfmr. / �
Alarm/Remote Conirol
Swimming Pool
I hereb certi thaf I ins fed ihe electrical insfallation described herein on the dates sfated
Irriqation Boom Q�,,,,�,i„ Dare
1 Investigative FeeF/ V L�1 c7 t¢ � - �`�t I,� 'zs �7' 1l
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFflCE USE ONLY This requesf void 18 moriths (rom validation daffi printed in fhis box.
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* 0 5 5 1 5 5 8 �* PLEASE PRINT OR TYPE ��'SL%
Requesf � fe� I /L, Rough-in inspecfion required? ❑ Yes o Inspecfion Other Than RougMn: Ready Now � Will Call
� � l (You musf call the inspecror when ready) Date Ready:
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I licensed contractor ❑ owner hereby request inspection of ifie above elecfrical work ot:
lob Address Sheef, Box or Route No.) City Zi Code
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Section
Range No. � Fire No.
Occupant �/` A/� , I l� (y/��/��. �
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Power���jl,T� jPy ��..''�11!*^1 �'+?' T(!_ ,y#b*e, �ss
dba: G'..r - � . :'�
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Elechical Con a, �r. (Company Npme) ��'
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Mailing Address �Contractor or Owner Performing Installation) "�
Aufhorized SignaNre
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Phone���
Masfer Lic. No.
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iTRUCTIONS ON BACK OF YELLOW COPY