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REQUEST FOR ELECTRICAL INSPECTION - -
Minnesota State Board of Electricity -
1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0 00 �,�
. Other: � d C �, New Addn
Indusfrial Farm �j� Remod Re
Htg. Equip. Water Htr. Load Mgmt. Other:
Range Elec. Heat Temp. Service
covered b this quest Enter remarks in ►his space an on he back of the white copy only.
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Fee - This Inspecfion Request will not be accepfed wifhout the correct fee:
Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobite Home Park Stalt 0 ro 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Am
Transformer/Generator INSPECTOR'S USE ONLY � ti� ���) TOTA
Si n/Oudine Ltg. Xfmr. F�
Alarm/Remote Conhol
Swimming Pool
I here certi ihat I ins fhe electrical in Ilation described herein on the daYes
Irri9ation Boom o,.,��., n..m
_� Investigative Fee � � � ��`� � �/l—� `—��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHI 18 MONTHS.
pFFICE USE ONLY This request vad 18 months from wlidafion dafe printed in this box.
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* � 5 3 2 5 7 9 �* PLEASE PRINT OR TYPE
Request Da�e Rough-in inspeclion required$ ❑ Yes ❑ No InspeMion O�er Than RougMn: ❑ Ready Now 0 Will Cafl
. �You musf call the inspecror when ready) Date ReadY: .
I, ❑ licensed confracror, owner hereby request inspection of the above electrical work ah
kb Addre Street, Box, or Roule .) A - Ciy � / Zip Code
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$ecfion No. Township Name or No.
Occupant /' �
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Elechical Conhaclor (Company Name)
Maili Address (Contrador r Ownar Pafi
Aulh '• innadu or Owner
Fire No.
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STpTE BOARD COPY - SEE INSTRUCTIONS O���CK OF YELL�W COPY