P - 80377„� REQUEST FOR ELECTRICAL INSPECTION
�� p O � � � � � � Minnesota State Board of Electricity �`”
O J 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.e%ctricity.state.mn.us '���
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusfrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htc Load Mgmt 01her.
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 copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Insfallations Fee # Service Entrance Size Fee # Circuits / 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 IfVSPECTOR'S USE OPVLY TOTAL �^ sp
Sign / Outline Ltg. Xfmr. /'� 5�"
Alarm/Remote Control
Swimming Pool ���
I hereb certi thaf I ins ected I i I n described herein on fhe dafes sfafed:
Irrigation Boom Rough-In Dare
Special Inspection
Final ?.�� Dafe : - �
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 ONTHS.
OFFICE 1�E ONLY This request void 18 months bom validation date prinfed in this box.
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Request Date Rough-in inspection required8 ❑ Yes ❑ o nspectio O er Than Rough-In: Ready Now � Will Call
You must call the inspector when ready Date Ready:
1, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Streel, Box, or Route No.) City Zip Code
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Secfion No. Township ame or No. Range No. Fire No. ty �
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OccupanR _ Phone No.
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Elechical Conhacfor J Company Name
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Mailing Address (Contracfor, Company or Owner Performing
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Aufhorize ' ature �Conhactor, Company or Owner Perfon
EB- -12 5/1999 STATE BOARD COPY
Confracfor License No.
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SEE INSTRUCTIONS ON BACK OF YELLOW Coav