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RE(�UEST FOR ELECTRICAL INSPECTION �- �
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone(612)642-0800
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Air Cond. Htg. Equip. Water Htr. Load MgrtfC Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on ►he back of the
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Caiculate Inspection Fee - This inspection Request �f�l not be accep►ed withovt the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/f
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Am
Street Ltg./Traffic Sig. Above 200 Am s Above 100
Transformer/Generator INSPECTOR'S USE ONLY � � � � �
Sign/Oudine Ltg. Xfmr. ��,, jg.ce-`
Alarm/Remote Conhol �� ��tt /C�T— ������
$wimming Pool �� 7 gd�> � 6 f�l
I hereb certi that I ins ted the elechical installaKon deuribed herein a
Irrigation Boom R�„�i,.i„ �—. i�
copy
Fee
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Investigative Fee /'
THIS INSTALLATION MAY BE ORDERED DISC CTED IF NOT COMPLETED WITHIN 1 MONTHS.
OFFlCE USE ONLY This requesf void 18 months (rom validalion dale prinfed in this box.
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* � 5 3 2 5 4 L �* PLEASE PRINT OR TYPE
Requesf Date Rough-in inspection required$ ❑ Yes ❑ No Inspection O�er Than RougMn: ❑ Ready Now ��II Call
�You must call fhe inspecfor when ready� Date Ready: �
I, ❑ licensed contractor ❑ owner hereby request inspection of the above elechical work at:
lob Addreu (Sheef, Box, or Route No.) Ciy Zip Code
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' n No. Township Name a No. Ranae No. Fire No. nN
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Power Sup r
Elechicol Conhactor �Company Name)
Moi{ing Addreu �Conhae�or or Owner PerG
Authorized SignaNre (Cqqtracfo�or Owner
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Phone No.
57 - 0679
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i. - Masler Lic. No. (I
266���
Phone No.
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BOARD COPY - SEE INSTRUC770NS ON BACK OF YELLOW COPY