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Home Duplex
RE(1UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Commercial Industrial Farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service �/
"X" above the work covered by this request. Enter remarks in this sp ce and on
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�ack 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
Mobile Home Park $tall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Ai
Transformer/Generator INSPECTOR'S USE ONLY TOT
Sign/Outline Ltg. Xfmr. �il� c dl-�� fr�t '�'�jr`�t "'
Alarm/Remote Control
Fee
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ri� S'o
Swimming Pool
I hereb certi that I ins ed the elechical insfallafion described herein on the dates stated
Irrigation Boom Rough-I� �°}e
Special Inspection pa�e�
Final f�,QL
Investigative fee � �^2� L
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 monihs from validafion dafe prinfed in this box.
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PLEASE OR TYPE
Request D/q�fe 1 Rough-in inspection requi�ed? ❑ Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now ❑ Will Call
//�2/ �O (You must call the inspeclor when ready) Date Ready:
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I, ❑ licensed contractor �owner hereby request inspection of the above electrical work at:
Job Address (Sfreet, Box, or Route No.�� �� �� C��� ��� Z�P�� �
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Secfion No. Township Name or No. Range No. Fire No. County /� /�
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Occupanf
Power
EB-00001
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Name�
or Owner
Phone No.
Conhacior License No.
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No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY