P - 838875,�°z - 612 �._
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other:
Commercial Industrial Farm
Air Cond. Htg. Equip. Wafer Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enier remarks in this space and on
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Calcula►e Inspection Fee - This Inspection Request will not be accepted without the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps / 0 to 100 Amps
$treet Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. ��'�
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ed the electrical installation described herein on the dates stated
Irrigation Boom Rough ln pa�e
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Investigative Fee �� <^ Z''L.-��i
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinfed in fhis box.
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PLEASE PRINT OR TYPE !'� .�'
Requesf Date Rough-in inspection required? ❑ Yes ❑ No Inspec}ion Ofher Than Rough-In: eady Now ❑ Will Call
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I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job A dress (Streef, Box oufe No.) � �'} City Zip Code
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Section No. Township Name or No. Range No. Fire No. Coun
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Power
Elecfrical Confractor (Company Name)
DF��"vD�,?iE ELEC7�iC. IhG.
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C�on R�pids, Mtd 55433
Authorized Siqnature (Conhactor or ormina I
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Phone No.
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x1tracfpr License No. Master Lic. No.
STATE BOARD PY - SEE INSTRUCTIONS
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