P - 82528�U�9�5-257 �
Home Duplex
Commercial Industri
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity �L, 3
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 =
(651) 642-0800 ww�v.electricity.state.mn.us " �
,4
Apt. Bldg. Othe �`� ` New Addn
Farm � Remod epair
Air Conditioner Hig. Equip. Water Hfr. Load Mgmf. Ofher: 1
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by this request. Enter remarks in this space and ack of the white copy only.
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Calculafe Inspection Fee - This Inspection Requesf will not be accepted without the corcect fee:
Other Installations Fee # Service Enhance Size Fee # Circuifs / Feeders Fee
Mobile Home Park 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 TOTA�I�^ �-7�
Sipn / Outline Ltq. Xfmr. e1-�• � v
Swimming P �
1 hereb certi tkat I ins ected the elecfrical installation described herein on the dates stated:
Irrigation Boom Rough-In Dafe
Special Inspection
Firwl
Investigative fee �C
`THIS INSTALLATION MAY BE ORDERED Dt_ _ ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONIY This rpuesf void 18 months from validation date printed in this box.
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* 0 9 2 5? 3* 30- ��
PLEASE PRINT OR TYPE
Reque� Da � Rough-in inspecfion required$ ❑ Yes o Inspection 01her Than RougMn: ❑ Ready Now ill Call
f( You must cal� the inspector when ready Dote Ready:
I, icensed ontractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Addr s k t, Box, or Roufe City Zip Code
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o� No.
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ress (Contractor`Company or Owne� r PerForming
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n re �Confracfo , Compan r ner Perfori
2 5��9 STATE BOARD COPY
No. � fire No.
InCv� � i s ��
SEE INSTRUCTIONS ON BACK OF YELLOW COPY