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RE(�UEST FOR ELECTRICAL INSPECTION --
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612)642-0800
Apt. Bldg. Other: New Addn
�I Farm Remod Re air
uip. Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
by thi request. Enter remarks in this space.and on the back of the white copy only.
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Calculaie Inspection Fee - This Inspection Request will not be accepted wifhout the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR•s use oN�v TOTAL�
$ign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted !he elechical installation dexribed herein on Ifie dates stated
Iffiqation BoOm RouaMn �O�e
Fee
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Investigative Fee — '" v `(i � — l •�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. _
OFFICE USE ONLY This request void 1 8 monihs Irom validation dafe prinTed in fhis box.
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�K ❑ 5 6 � Z � 9 9* p ASE PRINT OR TYPE
Request t� y Rough-in inspection required? ❑ Yes No Inspecfion Ofher Than RougMn: ❑ Ready N Will Call
/ � (You must call ihe inspector when ready) Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job �dre (S}re x, or Route No.) , City Zip Code
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Section No. Township Name or No. Range No. Fire No. Co nty � �
Occupant
Power Supplje����
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Phone No.
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NSTRUCTIONS ON BACK OF YELLOW
(Plant Elect.
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