P - 82337���9�-�52 �
REQUEST FOR ELECTRICAL INSPECTION °'E
Minnesota State Board of Electricity %
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ���
(651) 642-0800 www.electricity.state.mn.us `'�'
Home Duplex Apt. Bldg. Other:
Commercial Industrial Farm
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in ihis space and on
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Calculaie Inspection Fee - This Inspection Requesi will not be accepted without ►he correct fee;
Otfier Installafions 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. �r'�
Alarm/Remote Control
Swimming Pool I hereb certi that I ins cted Ihe elechical installation described herein on the dafes staled:
Irrigation Boom Rough-In �a�
Special Inspectio pa�
Final Cy-. Zn —OGS
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCON D IF NOT COMPLETED WITHIN 18 MONTHS.
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��� � � � OFFICE USE ONLY This request void 1 S months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dgte � Rough-in inspection required? ❑ Yes o Inspecfion Other Than Rough-In: eady Now ❑ Will Call
r� � You musf call fhe inspector when ready � Date Ready:
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I�] icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Add� �S�e9f, Box, or Roure No.) � �� City � / Zip Code
ownship Name or No. Range No. Fire No. CdGnty
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Phone No.
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� � � _ Address
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ictor / Company Name Conhac r Lic nse No. Masfer Lic. No.
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Mailing Address (Conlractor, Company or Owner Performing Installation)
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Authori �nature (Contracror, or OwnecPe orming Installation)
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EB-00001A-12 5/1
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SEE INSTRl1CT10NS ON BACK OF VELLtlW COPY