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Home Duplex
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
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Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. En►er remarks in this space and on the back of the whiie copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without ihe correcf fee:
Other 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 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. . �
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins d the electrical installafion described herein on the dates stated
Irrigation Boom RoogMn pare
Special Inspection
Find
Investigative Fee +—
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTNS.
OFFlCE USE ONLY This requesf void 18 months from validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Dppe /� Rough-in inspecfion required$ ❑ Yes No Inspecfion Other Than RoughJn: Ready Now ❑ Will Call
/O � '�q (You musf call the inspecfor when ready� Date Ready:
I, �censed contractor ❑ owner hereby request inspection of the above electrical work at:
lo���reyy'$ , Box, or R o.�� City �� �� Zip Code
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Section No. Township Name w No. Range No. Fire No. uny ,/J
Occupanf
Power Su�
Phone No.
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STATE A D COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY