P - 84006��� 1'b� 8 2 6�
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �_
Phone (612) 642-0800 ��'
Commercial In strial Farm
ir Co . tg. Equip. Water Htr. Load Mgmt. Other.
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in ihis space and on
New
copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�r TOTAL ��
$ign/Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool ���J
I hereb certi that I ins ected fhe elecfrical installaKon described�n th��s 9fGted �
Ifrigation Boom • �• .-._ -Aough-In � Dote
Special Inspection t� � 2
Firwl Da
Investigative Fee —
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validation date printed in ihis box.
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I III) II II) (I III I) II� II (II I II III II II) I I�) ( 3��
* 0 5 1 6 8 2 6 5* PLEASE PRINT OR TYPE ��rJ �
Request Daie Rou h-in ins tion re uired2 Yes
p (� g pec q ❑ No Inspection Olher Than Rough-In: ❑ Ready Now Will Call
/� �� p� �— J� �You musf call the inspector when ready) Date Ready: �
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job��ess (Sheet, Box, or Route No.) ��� City�� Zip Code
.� .� �.3 2/
Sectio� No. To nshi e or No. Rancte No. Fire No. unty
occupanr
Power Supp�ier Addre
ns�
Elechi al Conhactor (Company Name),
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Mailing Address (Conhactor or ner Performing Insfallafion) �,
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Phone No.
Coniratlor License No. Master Lic. No. (Plant Elect
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P' Phone No.
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VSTRUCTIONS ON BACK OF YELLOW COPY