P - 81128U���4-070 �1
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REQUEST FOR ELECTRICAL WSPECTION ��
Minnesota State Board of Electricity
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1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 :
(651) 642-0800 www.electricity.state.mn.us "��°
Home Duplex Apt. Bldg. Other; New Addn
ommercial ndustrial farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmf. Ofher:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this reque t. En�er remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - T s lnspection Requesf wil! nol be accepted wi�hou� ihe correct fee:
Other InstaAations Fee # Service Enkance 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 TOTAL C
Sign / Outline Ltg. Xfmr. � • J�
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the elechical installation described herein on the dates stated:
Irrigation Boom Ro„qh-i„ Date
Speciallnspecti � '
Imestigative Fee �� _ Date ,�}
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THIS INSTALLATION MAY BE ORDERED DISCON ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
_ __�.------ __
OFFlCE USE ONLV This requesf void 18 mon�hs kom validation date printed in fhis box.
I�II�IN�I��II���N�����(� • .a°�
* 0 8 8 4 0 7 0 4* ��53
PLEASE PRINT OR TYPE
Req�s�ta, � �� Rough-in inspection required$ ❑ Yes ❑ No Inspection Ofher Than Rough-ln: Ready Now ❑ Will Call
You must call the inspecror when ready Date Ready:
, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo A reu �Street, Box, or Rout City Zip Code
�`DO �' � �- �
Section No. Townshio Name or No. Ranqe No. Fire No. Couny f � �
c
I Power Supplier ���
rcical Conhactor / Company Name
DEPENDABLE Ft �r,TRtc
����355�e2Yfl°�y���Y ��e�
9�i
Ceon Rapids, MN �543;
iorized Signalure (Conha� , ompanyyc,�
Phone No. h y � ��
V
ddress
Conhacro icense No. �� Master Lic. No. �Plont Elect. Only)
33
�ning InstallaFion� r. }���---`yyy � : .
� � V ti '.t k
Perf m g Installation) Phone Number
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COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY