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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
Other: New
Commercial Industrial Farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Othec
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space an�
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on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be occepted without the correct fee:
Other 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 TOTAL �
Sign/Outline Ltg. Xfmr. � `
J `'
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the electrical.installation described herein on the dates s�afed
Irrigation Boom Rough-In Dare
Special Insp .
Final Date
Imestigative N 2�
THIS INSTALLATION MAY BE ORDERED DISCONNEGTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validafion dafe prinfed in this box.
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IIIIIII
* � 4 8 8 9 � 6 9�k P SE PRINT OR TYPE
R uest Date Rou h in ins ection re uired? p g ❑ Ready Now � Will Call
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"- � 1 �� �You must call fhe inspector when ready) Dafe Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address (Street, Box, or Roufe No.) � Cify / � Zip Code
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Secfion No. Township Name or No. Range No. Fire No. �County �`"
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Occupanf ti
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Power Supp�ier
Phone No.
I Coo actor (Company Name� -- .; Confractor License No.
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Address �Co9hactor or Owner Performir,� Installahon� /,.
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ed Signature �Conkaafo or r Perfocmina,l tPllaFion) ��
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A-11 8/96 STATE BOARD COPY 1 STRUCTIONS ON BACK OF YELLI
Masfer Lic. No. �Planf Elecf. Only�
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