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Duplex
RE(�UESI'"FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 Universiiy Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
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Commercial Industrial Farm Remoa RC
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
ryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesi. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted wiihout the correct fee:
Other Fee # Service Entrance Si e Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 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.
Alarm/Remote Control
Swimming Pool
Irrigation Boom
Specia� Inspe n� (�
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I hereb certi thaf I ins ed the eleclrica� installafion described herein on the dates sfated
Rough-In Date
THIS INSTALLATION MAY BE ORDERED DISCONNEGTED IF NOT COMPLETED WITHIN 18 MONTHS._
OFFICE USE ONLY This request void 18 monfhs from valiclaiion date printed in fhis box.
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Request Date Rough-in inspecfion required? ❑ Yes No Inspection Other Than Rough-In: eady Now ❑ Will Call
������ (You must call the inspector when ready� Date Ready:
I, �Jicensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address (Sireet, Box, or Rout No.) Ci Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Coun
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or Owner
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Installation�
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Phone No.
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No. Master Lic. No. (Plant Elec
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Phone �N`o.� ' I��
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