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REDUEST FOR ELECTRICAL INSPECTION ��°
Minnesota State Board of Eleciricity
1821 University Ave., Rm. 5-128, St Paul, MN 55104 .
Phone (612) 642-0800 �'
. Othec New Addn
dip. Waler Htr. Load Mgml. O�er:
Elec. Heat Temp. Servi<e
by �his request Enter �emarks in this space ond on the back of lhe whi�e copy
Colculole Inspecfion Fe ���spec>io� esf will��cepted wifhoN fhe correcf (ee:
T
line L�g. Xfmr.
mofe Conlrol
� Pool
Boom
# Service Entrance Size Fee # Circuifs/Feeders
0 fo 200 Amps 0 to 100 Amps
Above 200_Amps Above 100—Ar
INSPECTOH'S USE ONLV TOT�
thar I inioected the elecnicol iremllatian dsscubed herein on the doie: sirned
Fee
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� THIS INS7ALLATION MAY BE ORDERED DISCONNECTED If NOT GOMPLETED WITHIN 78 MONTHS.
I. __- __.._.._. —_._._—
OFFICE USE ONLY Thia �equesl void 18 monlhs irom volldation doM p�inted in �h1r bw.
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* 0 7 6 8 4 4 1 8 s ���(o
PLEASE PRMT OR TYPE :
Reqoest Dai ��� Rough in inspec�im reqaired2 ❑Yes No Inspection O�c Than Rwgh-In! eady Now 0 WIII Coll
5 (Vau mos� mll the I�spector when ready� Dore Reody:
I, licensed conhactor ❑ owner hereby requesl inspection of the obove elecfrical work ot:
Jab A�eys�rc�r, Box, a RoNe�/D 6.1 / i CIN ✓ .!/ Za Cada
I I Occ�Po^t //�
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Pho�e No.
�I Masler Lic No.
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INSTRUCTIONS ON BACK OF YELLOW COPY