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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1621 Universiry Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 =
(651) 642-0800 www.electricity.state.mn.us
Repair
Air Conditioner I I Htg. Equip. I I Waier Htr. I I Load Mgmt. I Other: I
Dryer �—�ange Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request wil t be accepted without e c1fi ' olrect tee: �
Other 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/Generotor INSPECTOR'S USE ONLY TOTAL
$ign / Outline Ltg. Xfmr.
Alarm/Remote Control 3 �sd
Swimming Pool
I hereb ceAi fhat I ins ted the elechical installation described herein on the dates stafed:
� RoupMn':+ � ; � � Date .
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Investigative Fee F�nai - /� �/'�`__� I Da�.� Z�� �
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED � NOT COMPLET'ED WITHIN 18 MONTHS.
� � � � OFFICE USE ONLY This request void 18 monfhs bom volidafion date prinied in Ihis box.
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PLEASE PRINT OR TYPE
Requesf Date Rou h-in ins cfion r uired?
9 Pe e9 ❑ Yes o Inspection Ofher Than Rough-In: ❑ Ready Now Will Call
� � You must call the inspector when ready Date Ready:
I, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Sheef, Box, o^Roufe No.�A w City r � Zip Code
or No. � Range No. � Fire
Occupant
Power Supplier � �
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Electrical Cont�acfor / Com�qny Name
Address (Contractor, Company or Owner Performing
Conhoctor
Phone No.
Master
BOARD COPY SEE INSTpUCTiONS ON BACK OF