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Industrial Farm
Htg. Equip. Wati
REQUEST FOR ELECTRICAL INSPECTION ��,
Minnesota State Board of Electricity � 3
1821 UniversiTy Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 ��
(651) 642-0800 www.electricity.state.mn.us `_'��
Other. New Addn
Dryer I, I Range I I Elec. Heaf - I ITemp. Service I
"X" above the work covered by this reque t. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Requesf will not be accepted without t rect fee:
Other Installations Fee # Service Enhance Size Fee # Circuifs / 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 TOTAI.��. /1
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irrigation Boom
$pecia� Inspectior�li�.
that I ins ted the elechical insmllation described herein on the da
Dare
1 Investigative Fee,,�'��j V L� � � � ��� ---�� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� OFFICE USE ONLY This requesf void 18 months from validation date prinfed in fhis box.
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PLEASE PRINT O TYPE
:quest Date Rough-in inspecfion required8 ❑ Yes ❑ No Inspeclion Olher Than Rough-In: Ready Now � Wiil Call
r`D � OQ You musf call the inspecfor when ready Daie Ready:
,�licensed contractor ❑ company ❑ owner hereby request inspection,ofl the above electrical work at:
i
b Addres;'�Sfreef, Box, or Route No.) � ` City _�� � � Zip Code
orT�o. � Range No. � fire No.
Occupant �/ � c
DEPEND,QBLE ELECTRIC, iNC.
e � 0AA or $j� jior � P
C�an Rapids. M�43 , �
ized Signature actor, Comparyy-erC�iner Perforyi
Phone No.
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Master Lic.
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SEE INST • ON BACK OF YELLOW COPY