P - 80238REQUEST FOR ELECTRICAL INSPECTION �
V�- J.O 1- 5 51 � Minnesota State Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 551044993 ��.
(651) 642-0800 www.electricity.state.mn.us "'
"X" above the work covered by tl
S ��ic.rr �I t �
Calculate Inspection Fee - This Inspection Request will not be accepted withouf the correct fee:
Other Installations Fee # 5�rvice Enhance $ize Fee # Circuits / Feeders Fee
Mobile Home Park Stall >0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. " Above 200 Amps Above 100 Amps
TransformerJGenerator INSPECTOR'S USE ONLY TOT
Sign / Outline Ltg. Xfmr. O•�
Alarm/Remote Control
Boom
that I ins ecfed the electrical installation described herein on the dates stated:
Dafe
Investigative "°°� � � .- � "°%`t3 �3 °3
�.
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� OFFICE USE ONLY This request void 18 monfhs from validation date prinfed in fhis box.
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PLEASE PRINT OR TYPE
�quest Da Rough-in inspecfion required$ ❑ Yes No Inspection Olher Than Rough-In: eady Now ❑� Will Call
1��� � You must call the inspector when ready Dafe Ready:
licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
�iress (Street, Bo�er�Route No.) � .— C� Zip Code
x L�l
Kfion No. Township Name or No. Range No. Fire No. � C un]y �
Occuyq�t�
Power�5�u�ppliet
Company or Owner
Signafure (CoMractor, Company or
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Contracior License No. I Master
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5/1999 STATF ROAROG�� SEE INSTRUCTIONS ON BACK OF YELLOW COPY