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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New
Commercial Industrial Farm Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Ofher:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enier remarks in this space and on fhe back of the white copy
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TO�AL �
$ign/Outline Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Pool �
Irriaation Boom i
�ar�9�� .=
the electrical instaliation d�ibed here� n� d�
X/
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Fee
investigative Fee " ` —
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHI 18 MON HS.
OFFICE USE ONLY This raquest void�8''months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe R h-in ins on r uired? � Yes pec g ❑ Ready Now ❑ Will Call
oug pecli eq ❑ No Ins fion Other Than Rou h-In:
�You must call the inspeclor when ready) Dafe Ready:
I, licensed confractor ❑ owner hereby request inspection of the above elechical work at:
Job Address �Street, Box, or Roufe No.) Ciy Zip Code
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Seclion No. Township Name or No. Rnnge No. Fire No. CounN
Occupanf
� t/ B�2SNt
Power Supplier
Elechical Conhacfor (Company Name�
Mailing A dress Conhacfor or Owner
(oZl d
4uthoriz,pe+Signature (Conhad r or O�
Phone No.
Master Lic.
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COPY - SEE INSTRUCTIONS ON BACK OF YE�LOW COPY