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REQUEST FOR ELECTRfCAL INSPECTIOfV
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
New
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Commercial Industrial Farm Remod Re air
Air C Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this request. Enter remar s in lhis space and on Ihe back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepied 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
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generotor INSPECTOR'S USE ONLY TOTA/L �''�)
Sign/Oudine Ltg. Xfmr. /�'J �
AlarmjRemote Conhol
Swimming Pool
I hefeb certi tlwt I in tad the electrical installation dexribed herein on the dates slaTed
Irrigation Boom RougMn Dare
Special lnspectio
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Investigative Fee o -e7�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED tF NOT COMPLETED WITHIN 18 MONTHS.
� OFFlCE USE ONLY This request void 18 months from vplidafion date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Date Rou h-in ins ion r uired? ❑ Yes ❑ Will Call
g pecf eq ❑ No Inspection Other Than Rough�n: Ready Now
• ' (You musf call the inspec�o� when ready) Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Jo ddress (Skeet, Box, or Roufe No.) � Ci � Zip Code
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Occupont
Power $uc
or No. � Range No. � Fire
uA�t,� ELECTRIC. C�IG.
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r o i InsD
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Siqno e(Confracfor or Owner Per r nc
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BOARD COPY - SEE INSTRUCTIONS
Phone No.
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�/ Master Lic. No. �Plant I
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Phone No.
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