P - 83484� REQUEST FOR ELECTRICAL INSPECTION
5 �,(� � 7�� Minnesota State Board of Electriciiy -
�� �J � 1821 University Ave., Rm. S-128, St. Paul, MN 55104
^ Phone (612) 642-0800
, Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re oir
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other: I
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. En►er remarks in ►his space and on the back of tFie white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted wifhout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Anips
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Oufline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi fhat I ins ed fbe e1��trical installafion described herein on the dates sfated
Irrigation Boom Rough-In lQ �� ��
Special Inspe r` Final ��r+ �
Investigative F / � � —
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesi void 18 months from validation da�e prinfed in this box.
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PLEASE PRINT OR TYPE
Requesf Date Rough-in inspection required$ �Yes ❑ No Inspecfion Other Than RougMn: ❑ Ready Now ❑ Will Call
����� (You must call the inspector when ready) Date P.eady:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
l Sv / a �rna �q F�[d�e 2-
Section No. Township Name or No. Range No. Fire No. County
Phone No.
`'7 �/ / �G.O
I I Power
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�iling Address (Contractor or Owner Performing Insfallafion�
3SS9 L,.� � ,�� Or�,��, �� , �'l. �/ ��3
thorj�d $iqnature 1 ontrflcfor or Owner Performinq Installationl ��/ P
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