P - 82417- REQUEST FOR ELECTRICAL INSPECTION - -
(� .� � � � � � � � � Minnesota State Board of Electricity
�� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us " '
Home Duplex Apt. Bldg. Other: New Addn
mercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
/���� /�v �� ���
Calcu ate Inspection Fee - This Inspection equest ill not be accepted without the correct fee:
Other Installations Fee # Service Enirance Size Fee # Circuits / Feeders Fee
Mobile Home Pork Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAj�� �
Sign / Outline Ltg. Xfmr. �J'
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the elechical installation described herein on the dafes stated:
Irrigation Boom Rough-In Dare
Special Insp
Final Da _� ' 2� rc �
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONN CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validafion date printed in this box.
I�� ,���.� •
II � II IN � I� � III N 18 II�III II III I I�I
* 0 9 8 5? 2 7 7 � ���Q
PLEASE PRINT OR PE
Requesf /���� Rough-in inspection required? ❑ Yes �o Inspection Other Than RougMn: eady Now ❑ Will Call
You must call fhe inspector when ready Date Ready:
I, �tcensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job A�ddyess heej�ox, or ufe N �� City �� �� Zip Code
�� ��'i . �r
Secfion No. Township Name or No. Range No. Fire No. Cou
d
Occupant Phone No.
Q��
Power Sup er 2 8 3�� Addrgs�� j� /J�� ��� ��
v C.
Elech' n c r/ Compony NaC,������' Coycpctor Lice�� �"� Master Lic. No. (Plant Elect. OnIY�
G ����
Mailing Add ss (Conha , Company or Owner Perfor i Installati n /
�.Ti� U/�'lC' � s 1'
Aufhoriz ign fure ( fmctor, Comp �� r Owner Performing Installafion) //� Phone N�_r�i/�� �_
bi � � �.(>
EB� � ST TE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY