P - 8416554�-�66 �
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REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. PaUt; MN 55104
Phone(612)642-0800
Apt. Bldg. Other: New Addn
Farm Remod Repair
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this request. Enier remarks in this space and on the back of tpe white copy
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Calculate Inspecfion Fee - This Inspection Request will noi be accepted wifhout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 3 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amp�
Transformer/Generator INSPECTOR'S USE ONLY TOTpjL
Sign/Outline Ltg. Xfmr. ���/:
Alarm/Remote Conhol
Swimmin Pool
9 I hereb certi fhaf I ins fed the eleclrical installafion described herein on fhe dafes stated
Irrigation Boom Rough-In Dare
Fee
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imesngarrve ree – — + � - - � —
THIS INSTALLATION MAY BE ORDERED DtSC NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 months from validation date printed in this box.
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* � 5 4 9 8 6 6 2�K PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection required2 ❑ Yes , No Inspection Other Than RougMn: ❑ Ready
�� ��, �� '�j 7 (You must call the inspector when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address �Shee}, Box, or Roufe No.� Cily Zip Co
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Secfion No. Township Name or No. Range No. Fire No. Couny
6; C��t
Occupanf Phone No.
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Power Supplier Address
�EI ical Confractor �Company Name) Conhador License No. Master Lic. No. �Plant Elecf. On
5��-�� j=l_�e�TiQrc. ���'� ��f�va/��
Mailin��Conhactor or Owner Performing Insfallation)
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Au�` i�,' ,$ignature (Conhacfor or Owner Perfor ng fallafion) � hone No.
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