P - 81211� ry REQUEST FOR ELECTRICAL INSPECTION .A
l.�— 8 7 7� 7 1 1 � Minnesota State Board of Electricity !
1821 University Avenue Suite 5-126, Saint Paul, Minnesota 55104-2993 ---
(651) 642-0800 www,electricity.state.mn.us �� �
Home Duplex Apf. Bldg. Other: New Addn
ommercial Industrial farm Remod Repair
Air Conditioner Hfg. Equip. Wafer Htr. Load Mgmt. Other:
Dryer ange Elec. Heaf Temp. Service
"X" obove ti�e work covered by il�is request. Enter remarks in this space and on tl�e back of the white copy only.
���i i� ' �
Calculate Inspection Fee - is nspection Reques► will not be occepted without the correct fee:
Other Installations Fee # Service Enhance Size Fee # Circuits / Fceders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generafor INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr. ��Q
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins cfed Ihe elechica� insfallafion described herein on fhe dafes sfafed:
trrigation Boom RougMn Dare
Speciallnspecti - h�
Imestigative Fee � � � 2 — G
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1$ MOMTHS. _
OFFICE USE ONLY This request void 1 S months from validation dafe prinfed in this box.
I�N���I����I��NI��NI��I���� • �°- �
* 0 8 7 7 7 1 1 2* �J���
PLEASE PRINT R TYPE
Request Daie Rough-in inspeclion required? ❑ Yes ❑ No Inspection Other Than RougMn: Ready Now ❑ Will Call
/� You must call fhe inspector when ready Date Ready: - �
�censed contractor ❑ company ❑ owner hereby request inspection of the above electrical work ah
1ob ddress (Street, Box, or R�ute; o� _ Ciy_ ^��� � Zip Code '�
Section No. � Township Name or
Occupanf `� �/� y� I �/� � Phone No.
�
:al Conhacror / Company Name
DEPENDABLE ELECTRIC. INC.
( �aor,���or�r P�ng Installation)
�eon Rapids, MN 55433 h �' � �
'ized Sipnalure �Conh , ompany or Owner Performinq Insfa i
�./ I I .YS / ���
COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY