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Home Duplex
Commercial lndustrial
REGIUEST FUR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800 /
TOther: New Addn
Farm
Water Htr.
Elec. Heat
request. Enter
Mgmt. Other:
Service
in this space and on ff�e
Remod
copy
Calculate lnspection fee - This lnspection Request will not be accepted without the correci fee:
Other fee # Servi e Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amp � 0 to 100 Amps
Street Ltg./Traffic Sig. Ab e 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL, �Cp.
Alarm/Remote Confrol
Swimming Pool
Irricaaii4n Boom
Ihat I insoecled Ihe
-o�n 1h-e dales srote�d
D! J °�-.'�'T .-_
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE II.SE ONI.Y This requesf void 18 monfhs from validation dafe prinkd in fhis box.
'! I!IIm �► 75-sd
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* O S(a 7 O O O S* PLEASE PRINT OR TYPE
Request Rough-in inapection required$ Yes ❑ No Inspection Other Than RougMn: ❑ Ready Now Will Call
� g (You must call the inspecror when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Jo� � O� Box,pr te No.) �="W,C.S/'I'� CAy ��� Zip Code
Ct
Mailing Address (Ca
. Aulhwized Signoiure
or
'' ""'"`CITIES ELFCTRIC, I�NC. CAOC381
310G-225TH ST. W., �C TPJ. W1N 55024
or Owner Pgrforming Inslallafyqn� d� t-3810
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Cou V
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Phone No.
or (Svmer Performifig InstallaKon��� �p��„� I Phone No.
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STATE BOARD COPY - SEE INSTRUCTONS ON BACK OF YELLOW COPY