P - 82515�U-98�_-287 �
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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity ��p �'
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.efectricity.state.mn.us `��'
Air Conditioner Htg. Equip. Water Htr. 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 the white
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Calculate Inspection fee - This Inspection Request will not be accep►ed wi�hout the correct iee
Other InslallaYions Fee # Service Enirance Size Fee # Circuits / Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to ) 00 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amp:
Transformer/Generator INSPECTOR'S USE ONLY TO�
Sign / Outline Ltg. Xfmr.
AlarmJRemote Control
Swimming Pool
I here cedi lhat I ins ted the electrical inatallation described herein on Yhe dates sh
Irriqation Boor� , eo�oh-In Dore
Repair �
copy
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Investigative Fee ��- 1������ ���. Jr ��� c%� �
THIS INSTALLATiON MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITIi1N 18 MONTHS.
OFFICE USE ONLY This �equest void 18 months from validation date printed in Ihis box.
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* 0 9 8 1 2 8 7 6 * �,�`u��� �
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PLEASE PRINT OR TYPE
�e9O � „„` Rough-in inspection required? ❑ Yes o Inspection Other Than Rough-I�: ❑ Ready Now ill Call
L%t% You musf coll the inspecror when ready Date Ready:
I, �.licensed contractor ❑ company ❑ owner hereby request inspection of the above electricai work at:
Job Address (Sheet, Box, or Route No.J Ciy Zi Code
�360 oN�a� �r" (Z�Dt�Y ��.
Section No. Township Nome or No. Range No. ire No. Couny
Occupanf
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6
Name
;CT�1� �NC
npany or Owner Performing installatiqp�
�`� �11eC.t..E f�
. Company or Owner Performing Installal
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STATE BOARD COPY
Phone No.
License No.
Master Lic. No.
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SEE INSTpUCT10NS ON BACK OF YELLOW COOv