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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us
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Commercial Industrial Farm emod Repair
Air Conditioner Hfg. Equip. Wafer Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above �he work covered by this reqvest. Enter remarks in this space and on the back of the white copy only.
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Calculaie Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Ofher Installations 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. Q_ S,�
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the electrical insfallation described herein on the dates stated:
Irrigation Boom Ro„gh-i„ Date
Special Inspection `�`
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Investi ative Fee
_THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 1 8 monfhs from validafion dafe printed in this box.
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PLEASE PRINT OR TYPE
Request Dafe Rou h-in ins ection re uired?
9 p q ❑ Yes �,1Jo Inspection Ofher Than Rough-In: .�ady Now ❑ Will Call
� D You must call the inspector when ready Da}e Ready:
1, �licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Streef, Box, or Roufe No.) Cify Zip Code
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Secfion No. Townshipi�la
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Power Supplier /
Elecfrical Contracfor / Comp
Mailin cidress (Confracfor,
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Authorized $ignafure � ra
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Address
o �Owner Per�ming Insfallotion�
Phone No.
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License No.
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Masfer Lic. No. (Planf
Phone Number
SEE INSTRUCTIONS ON BACK OF YELLOW COPY