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"X" above the
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paui, MN 55104
Phone(612)642-0800
Other: �n' New
Farm �'�� �'n �""" Rem<
Water Htr.
Elec. Heat
is request. Enter
Mgmt. Other:
Service
in this space and on the back of the white copy
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Colculate Inspeciion Fee - This Inspeciion Request will not be accepted wiihout the correct fee:
Other Fee # Servi ntrance Size Fee # CircuitsJFeeders Fee
Mobile Home Park Stall t 200 mps 0 to 100 Amps
Street ttg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T TAL �?�f
�v
Sign/Oudine Ltg. Xfmr. { -
Alarm/Remote Control � 8 � � �
Swimming Pool
1 here certi that I ins the elechical insfallafion described herein on 1he dates sfa�ed
_ Irrigation Boom Ro�M� �
Specia� Ins tion � 8
Imestigative fee f�� Z_�_�3 Dar� (��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validation date printed in this box. _
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* 0 8 0 2 2 7 1 `? � �! � Q �'� ?p <o,[jo�} 7i�7 �
PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? �Yes ❑ No Inspecfion Other Than Rough•In: ❑ Ready Now,-ig.Will Call
�You must call the inspecror when ready� Dafe Ready:
I, ❑ licensed conhacror � owner hereby request inspection of the above electrical work at:
Job Address (Streer, Box, or Roure No.) C�y LP C°�
��lt (.�J w.,��tr (_K IOQ C=i�Dt,r.� _ �s
or No. � Range No.
Occupanf
Power Supplier
�
Elechiml Conkactor
Mailing Address (ConfracFOr or Owner
��f -� ! - %� A ,
License No.
No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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