P - 82127� REQUEST FOR ELECTRICAL INSPECTION �
(1 � Q � � � � � � � Minnesota State Board of Electricity � �'
�� � 1827 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
Air C i er Htg. Equip. Water Hir. Load Mgmt. Other:
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
��-,�T c�� ��
6sl - 7 7� - `�7�SS
Caicu►ate Inspection Fee - This �nspection Request will not be accepted without the correct fee:
Other Insfallations 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 Amps
Transformer/Generato� INSPECTOR'S USE ONLY TOSQ�^ c
Sign / Outline Ltg. Xfmr. p�C/�
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the electrical instollation described herein on the dates stafed:
Irriqation Boom R�,,,,tii„ n„�,
nnal / - I uar�.. _/7 �,,,�,� I
Investigative ( ' ��-�• ��•
THIS INSTALLATION MAY SE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 1 S months from validation date printed in this box.
Ii�����,1����1������������ ��� � ao-�
* � 9 1 7 6 1 3* � 7�7` /
PLEASE PRINT OR TYPE
Request Dafe Rough-in inspecfion required? ❑ Yes. o Inspection Ofher Than Roughan: ❑ Ready Now ill Call
�'� � You musf call the inspecfor when ready Dafe Ready: -
I, icensed contractor ❑ company ❑ owner hereby request inspection oE the above electrical work at:
JCC IIY�111YV IIVIYJ V1� OM4n Vr IGLLV�� �.v�•