P - 825010-��83-913 Q
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -
(651) 642-0800 www.electricity.state.mn.us "�'
iome Duplex Apt. Bldg. Ofher: New v.ac
�o ercial Industrial Farm Remod Rep
Air C i" er Htg. Equip. Water Hir. Load Mgmt. Other:
Bryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Requesf will not be accep►ed without the correct fee:
Other Installations Fee # Service Enhance 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 Am s
Transformer/Generator INSPECTOR'S USE ONLY
Sign / Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the eleckical installation described herein on the dates stated:
Irriaation Boom R�„�ti_i„ Da�e
Final �° 7 �0O
Investigative j� i �— -� � ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� �' �OFFICE USE ONLY This request void 18 months 6om validation date prinfed in this box.
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* 0 9 8 3 9 1 3 5 * �����
PLEASE PRINT OR TYPE
Requesf Daie ��� Rough-in inspection required? ❑ Yes . Inspecfion Other Than Rough-In: ❑ Ready Now �Will Call
� You must call fhe inspector when ready Dafe Ready:
I�`I+censed contractor ❑ company ❑ owner hereby re uest in the above electrical work at:
1ob Address �Street, Box, r ute No.)
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Secfion No. Township Name or No. Range No. �- Fire No. unty �
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�plier Address
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Contractor / Co cb � �
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,ddress � ontmcror, Company or Own Performing Installati�
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d S' onfractor, Com ny or Owner 9 rming Insh
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A-�2 STATE BOA
Phone No.
3-
x License No. Master Lic. �
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SEE INSTRUCTIONS ON BACK OF VELLOW COPY