P - 82600REQUEST FOR ELECTRICAL iNSPECTION
U� ("� /� � � � � p � Minnesota State Board of Electricity �'�::
.��f 0 1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
� (651) 642-0800 www.electricity.state.mn.us -*r��"
"X" above the work c�
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request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Installations Fee # Service Enirance 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 TOTAL �
Sign / Outline Ltg. Xfmr. , �
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the electrical installation described herein on ihe dates stated:
Irrigation Boom Rough-In Date
Special Inspection '
Investigative fee Final f /� �
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Date Rou h-in ins ection re uired?
,�+ g p q ❑ Yes �,No Inspecfion Other Than Rough-In: '�$gady Now 0 Will Call
You must call fhe inspector when ready Date Ready:
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I,�licensed contractor'�„company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Streef, Box, or Ro\te Ng,J� �� Cifyr� Zip Code
ip Name or No.
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Company me°
�acto� ompqny � Owner PerForm`n
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"' ) cror, Company or Owne
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STATE BOARD COPY
No. Pire No. Co�ty � ^ _ "
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Phone No.
; C� ra- 7 - � 330
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C iracior License No. Master Lic. No. (Plant Elect. Only)
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5t ion) Phone Numkter
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY