P - 80331�r-$9�-400 �
Farm
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity a
1821 University Avenue Suite 5-128, Sai�t Paul, Min�esota 55104-2993 �;
(651) 642-0800 www.electricity.state.mn.us
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in ihis space and on the back of the white copy
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Calculate Inspection Fee - This Inspection Request will nof be accepied wiihout the correct fee:
Other Installations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
L
Sign / Outline Ltg. Xfmr. �_,.
Swimming Pool
I hereb certi that 1 ins cted the elechical installation deuribed herein on the da
Irriqation Boom Rouah-In Date
� � Investigative Fee � � � � ��-'—Gu �
THIS INSTALLATION IIAAY�E ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. �
OFFICE USE ONLY This requssf void 18 months (rom validation date prinfed in fhis box.
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* D 8 9 9 4 0 0 6 * �71J�
PLEASE PRINT OR TYPE
Request Date Rough-in inspection required$ ❑ Yes ❑ No Inspection Other Than Rough-In: eady Now � Will Call
��� � Q � You must call the inspecfor when ready Date Ready:
1, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sfreet, Box, or ute No.� � Cit�/ Zip Code
59 v� �V►� J�
Section No. Township ame or No. Range No. Fire No. C uny _
_ �
Jier , Addre:
mtrac(to1r -/ Compan Name ,
�Lt�� �1 IC
�ress (Confracfor, Company or Owner Performing Ins I6
�� ( V'
Signature �Contracfor, Company or Owner Performing Ir
STATE BnARD COPY
Phone No.
Conhactor License No. � I MasMr lic.
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RFE INSTRIICTIONS ON 9ACK AF YELL�W C[fPY