P - 81561REQUEST FOR ELECTRICAL INSPECTION �
y��y,/y1 Minnesota State Board of Electricity �'
'� �.1 J�- 2 5 8� 1821 Universiry Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 -
(651) 642-0800 www.electricity.state.mn.us
"X" above the work covered by this request. Enter remarks in this space and on the ba k of the white c
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Calculate Inspection Fee - This Inspection Request will not be accepied without ihe 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 TOT
Sign / Outline Ltg. Xfmr. / �.,��
Alarm/Remote Control
Swimming Pool
I hereb ceni that I ins ected the eleckica) insfallafion described herein on the daies sfated:
Irrigation Boom RougMn pore
Special Inspect
Investigative Fee F��wl �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS�
� � � OFFICE USE ONLY This requesf void 18 months from validati� ate printed in fhis box.�
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PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required$ ❑ Yes No Inspecfion Other Than Rough-In: ❑ Ready Now ill Call
I � �/� a� You must ca�l the inspector when ready Date Ready:
I�icense contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Addreu ($freer, Box, or Route�,�. A e _ Ciy' Zip Code
w .� i
I$ecfion No. I Township`Rame or
P�'�,�--�;�/-��`�
License No. � Master Lic. No.
Company o70wner Perfor�g Installafion)
or
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EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY