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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity `:3
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 64 - A
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Apt. Bidg. Oth :, � New Addn
Farm ` �7 �— Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspeciion Request will not be accepted 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
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOWS use oN�v TOTqAL
Sign/Oudine Lig. Xfmr. O`0, s�
Alarm/Remote Confrol
Swimming Poot I hereb cerfi that I ins th� eI�L'Iricbl iiuTallafion described herein on the da�es sMted
Irrigation Boom RougMn
Special Inspection ��`�
Final
Investigative Fee '"�'
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 mo�ths from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date � R h-in ins on uiredZ ❑ Yes
oug pecfi req ' ❑ No Inspection O�er Than Rough-In: ❑ Ready Now 0 Will Call
/O`��� � (You must call Ihe inspecfor when ready� Date Ready:
I, ❑ licensed contractor�.owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Roure No.) City Zip Code
3� 7- (� '�' r� �/. `� : l�=r; r� � j z
Section No. iownsiiia Name or No. Ranae No_ Fire No. Cou .
Phone No.
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naa� f�� /�
pLs /l,��f�{ Ul L%,
Name) Conhacfor License No. Moster Lic. No.
w Owner Performing InsMllafion, �� 4�2. .
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�fOr Owner Pe ing Insfallation) PI
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY