P - 82155U-�48-765 �
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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity 3
1821 tJniversiry Avenue Suite 5-128, Saint Paul, Minnesota 55704-2993 ��:
(651) 642-0800 www.electricity.state.mn.us '� �
Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other. �
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this uest. Enter remarks in this space and on the back of the white copy only.
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Calculate lnspection Fee - This lnspection Request will not be accepted wiihout the correct fee:
Ofher Installations Fee # Service EnTrance Size Fee # Circuits / Feeders F
Mobile Home Park Stoll 0 to 200 Amps 0 to 100 Amps �
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAC�r�� �
Sign / Outline Ltg. Xfmr. Iq'K•S'i�"`f ��'��'�
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the electrical installation described herein on fhe dates sfated:
Irrigation Boom Rough-In Dare
Special Inspectio
Final D
Investigative Fee �-6��3
THIS INSTALLATION MAY BE ORDERED dISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY TAis request void 18 mon4hs from validation date printed in this box.
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PLEASE PRINT O TYPE
Request �at Rough-in inspection required8 ❑ Yes o Inspection Other Than Rough-In: eady ❑ Will Call
You musf call the inspecfor when ready Date Ready: � bO
I,�licensed contractor ❑ company ❑ owner hereby request inspection of the above efectrical work at:
Job A ss (Sheet, Bo or Roufe No.� �� City �� _ f'� Zip Code �
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Section No. Township Nam o. Range No. Fire No. County
Occu� _ _ � ��
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Power Supplier �� Addre:
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Electrical o ra r/ Com a�Name� � �
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Mailing Addr s �C tractor, Com any or Owner Performi g Install
Authorize ign ture Co oc r, Corllpany or Owner rforming 4
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EB-OOOOtA-12 5/1999 STATE BO COPY
I�.1'U- 11( l'IQUOD I
SEE INSTRUCTIONS ON BACK OF YELLOW COPY