P - 80255o � REQUEST FOR ELECTRICAL INSPECTION
U��� O- 8 5 3 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
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other;
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesf. Enter remarks in this space and on the back of ihe white copy only.
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Cplculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Installations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic $ig. Above 200 Am s Above 100 Amps
Transformer/Generafor INSPECTOR'S USE ONLY TOT/9�
Sign / Outline Ltg. Xfmr. �s��•S�
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins fed the elechical installation described herein on the dates stated:
Irrigation Boom RougMn �re
Special Insp
Final - � Date Q.
Investigative — �
� THIS INSTALLATION_MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validafion date printed in this box.
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PLEASE PRINT OR TYPE
Reque� D�� � Rough-in inspection required? ❑ Yes o Inspection Ofher Than Rough-In: eady Now ❑ Wiil Call
dYou must call the inspector when ready Date Ready:
I, ensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Street, Box, or Route No.) Ciy Zip Gode
8 3 p ��o �� D2� �✓� �.�nc.+�, s�"�l 3 a
Section No. Township Name or No. Range No. Fire No. Cou
19"�'`�01�.4
Occupant Phone No.
�'06+� s'c W� tMa-/c.TZ. Co t��' 7�f -�s'a.3
Power Suppli� � Address °� � L � � ���. ��I, ��� .
N�� 3
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Electrical Conhactor / Company Name Confractor L' ense No. Masfer Lic. No. (Planf Elecf. Only)
�Ai�i��rc. �-�ne..�c. yN �-. C�rx�Zc �S' p-mo� � �3
Mailing Address (Contracfor, Company or Owner erforming Installafion)
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Authori Si ture � onh or, an Owner Perfo g sta ti Phone Number
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EB-00 01A-12 5/1999. S A BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY