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REGIUEST FOR ELECTRICAL INSPECTION � ..
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 -
Phone (612) 642-0800
Apt. Bldg. Other. �j�L�qC� �s'!s�'�<r.�-'.� New Addn
Farm Lao�� LYIr Remo Re air
Water Htr. Load Mgmt. Other: / QQ ,�/l7
Elec. Heat Temp. Service �`
this request. Enter remarks in this space and on the bpck of the white copy only.
Calculaie Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entranc Size Fee # Circuits/Feeders
Mobile Home Park Stoll to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Ar
Transformer/Generator INSPECTOR'S USE ONLY TO�T
Sign/Outline Ltg. XFmr. O�
Alarm/Remote Control
Swimmina Pool
Fee
; ,S'b
ihat I ins the electrical instollafion described herein on the dates sla�ed
Dafe
Investigative Fee '"`—�� �- ' �6--�
THIS INSTALLATION MAY $E ORDERED DISCONNECTED IF NOT COMPLETED WIT�iIN.1_8 MON
OFFICE USE ONLY This roquesf void 18 ths from volidation dafe prinfed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Date Rough-in inspection required? ❑ Yes o Inspecfion Other Thon RougMn: ❑ Ready Now ill Call
(You must call fhe inspector when ready� Daie Ready:
I, ❑ licensed contractor �wner hereby request inspection of the above electrical work at:
1ob Address (Sheet, Box, or Route No.) Ciiy Z�P C°�
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Section No. Township Name or o. Range No. Fire No. Couny
Occupant
Mailing Address (Conhactor or Owner
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Conhacfor License
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Phone No.
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�. Masfer Lic. No. (Planf EIeM. OnF
Phone No.
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COPY - SEE NS ON BACK OF YELLOW COPY