P - 81086.
(�-895-607 �
Home
Farm
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity 3
1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 �;
(651) 642-0800 www.electricity.state.mn.us
Remod � � Repair
Air Conditioner Htg. Equip. Water Htr. 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 1 sp ction Request will not be accepted wiFhout the correct fee:
Other Installations Fee # Service Enhance 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/Generator INSPECTOR'S USE ONLY TOTAL �
Sign / Outline Ltg. Xfmr. O�� �
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the elechical instollation dexribed herein on the dafes stated:
Irrigation Boom _ Rough-In Dare
Special lnspectio�
Investigotive Fee �I �� --Z. �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 1 S months 6om validation date printed in this box.
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* 0 8 9 5 6 0? 0* ��4��
PLEASE PRINT OR TYPE
Request Dafe Rough-in inspecfion required? ❑ Yes ❑ No Inspecfion Other Than Rough•In: Ready Now � Will Call
r You must call the inspector when ready Date Ready: -� �
I,'�licensed contractor ❑ comppny ❑ owner hereby request inspection of the above electrical work at:
C
rJob Address (Str�, Box, or Rou�No�j ` � _ � w City� � � Zip Code �'
SecM1On No. Iownshi�TiQomB o�
Occupant
Power Supplier.
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ri�" f����Qi�nfr l\ C�
Aufhorized Signafur ractor,
!B-0 1A-12 5/1 9
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„�_ Nw
�olQvner Performing
�7 v
moanv or Owner PerFon
Fire No. Counfy�
Phone No.
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�onhacfor License No. Master Lic. No.
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INSTRUCTIONS ON BACK OF YELLOW COPY