P - 78351REQUEST FOR ELECTRICAL INSPECTION -
U� � �`� � � � � � Minnesota State Board of Electricity ?a
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-08 0 www.electricity. t te. u "�'
Home Duplex Apt. Bldg. Other: � New Addn
Commercial Industrial Farm $�� iu.� C"TiT �/'�+" �^ (�( ���Q(i'� Remod Repair
Air Conditioner Htg. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heaf 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:
Other Installations Fee # ervic Enhance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 1 QO Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �
$ign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Poo
I hereb certi that I ins cted the electrical installation described herein on the dates stated:
Ir�igation Boom Rough-In Dare
Special lnspection _
Final � �%
Investigative Fee
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTFIS.
' � OFFICE USE ONLY This requesf void 16 monfhs 6om validafion date prinfed in this box.
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PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection required$ ❑ Yes No Inspecfion Other Than Rough-In: ❑ Ready Now �Will Call
�� � D3 You musf call the inspector when ready Date Ready: �
1, ❑ licensed contractor ❑ company �owner hereby request inspection oF the above electrical work at: I
Job Address (Sheet, Box, or Route No.) Ciy � Zip Code
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Secfion No. Township Name or No.
Occupant .
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Power Supplier
Elechical Coniractor�ompany Name -
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Phone No.
s��� �d –�� 7— ��
►Ls a ��-1 c �rsiv�
Contra�ror License No. Masfe� Lic. No. �Planf Elecf. Only
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(Contmctor, C,�npany or � er P�erforming Installation� �
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tur Conhacfor, or Ow rForming Installafion)
1999 STATE BOARD COPY
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SEE INSTRUCTIONS ON B CK OF YELLOW COPY