P - 82329REQUEST FOR ELECTRICAL INSPECTION
(1 �� J Q � � � 'I 'i � Minnesota State Board of Electricity � ,
�� �� •1- 1 1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -
(651) 642-0800 www.electricity.state.mn.us
Home Duplex Apt. Bldg. Other: New Addn
ommercial Indus}rial Farm Remod Repair
Air Conditioner Htg. Equip. Water Hir. Load Mgmf. Ofher:
Dryer Range Elec. Heat Temp. Service
„X" above the work covered by this requesi. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspecti n Req st will not be accepted wi►hout the correc� fee:
Other Insfallations 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 TOT/jly� �
Sign / Oudine Ltg. Xfmr. G•
Alarm/Remote Conhol
Swimming Pool
1 here certi that I ins ted the electrica) insfallation described herein on fhe dates stated:
Irrigation Boom RouAh-In Date
rmoi va � .Zd., p
investigative F —=�—
THIS INSTALLATION MAY BE ORDERED DI ECTED IF NOT COMPLETED WITHIN 18 MONTHS• �
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. OFFICE USE ONLY This requesf void 19 months from validafion date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Requesf '� R\ RougMin inspection required8 ❑ Yes o Inspection Other Than Rough-In: Ready Now ❑ Will Call
� O You musf call the inspector when ready Date Ready:
I,�censed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Addr ss� t, Box, r R fe N. /% . / City ��� Z�P C�
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Secfion No. Townshio Name or No. Ranpe No. fire No. uny ,/f .
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Signafu ontmcf � o n Owner Perfon
2`,�/�9 A E BOARD COPY
Phone No.
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" Con cfor License No.
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY