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REQUEST FOR-ELEC'; RICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
New
Industrial Farm % — vt %� �ar G_ Remoc
Htg. Equip. Water Htr. Load Mgmt. Other:
Range Elec. Heat Temp. Service
covered by this request. Enter remarks in this space and on the back of the white copy
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Calculate Inspection Fee - This Inspection Request will noi be accepted without the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins fhe elechicol installafion described herein on the dates smfed
Irrigation Boom RougMn Dare
Special Inspection — ' �
Fino� � Dar� ,� `9'L
Imestigative Fee -`
THIS INSTALLATION MAY_BE ORDERED QISCONNE TED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 months kom validation dafe printed in this box.
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PLEASE PRINT OR TYPE 'Sl�� �
Request _^ Rough-in inspecfion required? ❑ Yes
❑ No Inspection Oiher Than Rough-In: ❑ Ready Now ❑ Will Call
C� �You must call the inspector when ready) Date Reody:
I, ❑ licensed conhactor ❑ owner hereby request inspection of the above electricai work at:
Job Addres�� treef, Box, or Rqute No. � - n � City Zip Code r�
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$ecfion No. Township Name w No. Range No. Fire No. ounty
Occupant
Electrical Conhacror (Company
Mailing Address �Conhacfor or
Signalure (Conhactor or
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InstallaKon)
Phone No.
Contractor License No. � Master
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELI.OW COPY