P - 80322REQUEST FOR ELECTRICAL INSPECTION
r, ���' O�� � Minnesota State Board of Electricity 3
6,,.J 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 i�
, (651) 642-0800 www.electricity.state.mn.us '�'
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Calculate Inspection Fee - This Inspection Request wili not be accepted without the correct fee:
Other Installations Fee # Service Enirance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 t Am �
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control �
Swimming Pool
I hereb certi that I ins ted the electrical installation described herein on the daies stated:
Irri9ation Boom Rough-In Dare
Special Inspecti
� Final . Dafe
Investigative Fee — — =
THIS INSTALLATION MAY BE ORDERED DiSCONN�CTED IF NOT COMPLETED WITHI _18 MONTHS`: _
�� OFFICE USE ONLY This requesf void 18 months 6o yb�' at n date prinTed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Date Rough-in inspection required? ❑ Yes No Inspecfion Other Than Rough-In: Ready Now ❑ Will Call
v��^ �O You must call fhe inspector when ready Dafe Ready:
1, licensed contractor ❑ company ❑ owner hereby r quest inspection oF the above electrical work at:
Jo Ad ress (Sh t, Box, or Route No.� �G'jQ �G �Vl Ciry Zip Code
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Section No. Township Name or No. Range No. Fire No. Co ty
ddress
x / Company Name r �
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:onhacfor, ompany or Owner Performing Installafio
� Y�JC,�G� V' � a`. K �
ire (Con�ctor, Gompany or Owner Performing Inst�a
9� STATE BOARD COPY
Phone No.
SS/�° c�c�?3 (�51-f.33
License No.
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Phone Number
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