P - 84446OFPICE USE ONLY This request void 18 monfhs from validation dafe printed in this box.
� •��
�(��� (� ��� �� ��� �� ��� i III II ��� �� (�� �� ��� �� ��� ((��� ��
* � 4 2 ,G 3 3 8 4* � PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required? ❑ Yes No Inspection Ofher Than Rough-In: Ready Now ❑ Will Call
��,��/Q� (You must call ihe inspector when ready) Date Ready:
I, license� contractor ❑ owner hereby request inspection of the above electrica) work at:
Job Address �Sheef, Box, or Roufe No.) City Zip Code
OD r P�S'�" � Z l�L�i
Seclion No. Township Name w No. Range No. Fire No. Count�
Occupanf
fL
Conhador License No.
Mailing Addre�ye�(�Conhaclor or Owner PerForming Insfallafion) '
1�
COPY - SEE INSTRUC710NS ON BACK OF YELLOW COPY
� RE(�UEST FOR ELECTRICAL INSPECTION
��� a�'� Q_ Minnesota State Board of Electricity
J? 4�� 1821 University Ave., Rm. S-128, SL Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New dn
Commercia) Industrial Farm Remod Re air
Air Cond. tg. Equip. Water Hfr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of ihe white copy only.
� u� ��� �
Calculate Inspecfion Fee - This Inspection Request will not be accepted without ►he correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA� ,`
Sign/Outli�e Ltg. Xfmr. n�
Alarm/Remote Control
Swimming Pool
I hereb certi fhat I ins ed the elechical installation described herein on the daies sfated
Irrigation Boom Rooyh-In Dare
Speciallnspectio �
RneF- � Date �
Investigative Fee ` 2 ^3 —��
THIS INSTALLATION MAY BE ORDERED DISCONN CTED IF NOT COMPLETED WITHIN 18 MONTHS.