P - 8321265�a2L.V
REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity `�
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 "�'
icslex Aot. Blda. Other. . _ New Addn
Commercial Industrial Farm C� K'
Air Cond. Htg. Equip. Water Htr. Loa Mgmt. Other.
Dryer Range Elec. Heat Temp. Service
"X"°� the work covered by this request. Enter remarks in this s ace and on the back of �he white
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Calculate Inspection Fee - This Inspecfion Request will not be accepted without the correct fee:
Other Fee # Service Entranc ize Fee # Circuits/Feeder,
Mobile Home Park Stall 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 A
Transformer/Generator INSPECTOR'S USE ONLY T�
�
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irricaation Boom
I herebvi certifv that I inspected ihe eleclrirnl installalion described
copy only.
stated
Fee
Investigative Fee �" ��`� v � � �—� - I /--.�L 7" /. � �
H�S INSTALLAIION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 AI�ONTHS.
I�� I) �II �� I�I OFFICE USE ON�Y This request void 18 monfhs from validation date printed in this box.
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e �,�s
PLEASE PRINT UR TYPE
� Rough-in inspecfion requiredZ ❑ Yes o Inspeclion Ofher Than RoughJn: ❑ Ready N ill Call
u must call tfie inspecfor when ready) Dafe Ready:
contractor ❑ owner hereby request inspection of the above electricaf work ar
Box, or Route No.) � City � Zip Code
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iship Name or No. Ranpe No. Fire No. CounN �
or Owner
Phone No. �
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se No. Master Lic. No.
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Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW