P - 81027REQUEST FOR ELECTRICAL INSPECTION °'E_
�7 /� ���/� Z � Minnesota State Board of Electricity
/ 4i �} 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �`
.� Phone (612) 642-0800 "�'
ome Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Fprm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other: /
Dryer Range Elec. Heat Temp. Service �%2 C G( �
„X" above fhe work covered by this request. Enter remarks rn this space an ort the back of the white 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 Lig./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT
Sign/Outline Ltg. Xfmr.
Alarm/Remote Confrol ��, S D
Swimming Pool
I hereb certi that I ins ected the elechical ' Ilation described herein on 1he dotes stated
Irrigation Boom Rough-In Date
Special Ins . � -!✓? �
Final � Q _ Da
Investigative ee �--- .- �
THIS tNSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months From validafion date printed in fhis box.
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PLEASE PRINT OR TYPE
Req�esf Rough-in inspection required2 es ❑ No Inspection Ofher Than Rough-In: ❑ Ready Now�Wifl Calf
`O , � (You must call the inspecfor wh n ready) Date Ready:
I, �,licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheef, Box, or Route No.� C� Zip Code
! ' /�/ L � ' ✓L/ �W
Section No. Township Nqme o� No. Range No. Fire No. County
Conhador
� IP�g�
Conhador
ss (Conhactor or Owner Performing Installation�
o C� c��, �s MN SSo�
�nature ( actor or Owner PerForming Installa�' y�� Phone �_
, �Gi���i.3 �
$�96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY