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REQUEST 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
Farm Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspeciion Request will not be accepted without fhe correct fee:
Other Fee # Service Entrance Siz Fee # Circuits/Feeders Fee
Mobile Home Park Stall 00 Amps � 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T'O�TAL SO
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool �./ �—G�' �
I her certi Ifiaf I ins the electrical installafion described h m on dates
Irrigation Boom RougMn � � �../
Special Inspect Qde y
Fina� �1 �l� ��
Investigafive Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE I�E ONLY This request void 18 months from validafion dale printed in this box.
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IINIIII�IIIIIIIIIII IIIIIIIII�IN�I�N ����
* � 5 6 6 9 7 9 L* PLEASE PRINT OR TYPE
Requesf Date Rough-in inspection requiredi Yes ❑ No Inspecfion Other Than RougMn: ❑ Ready Now Will Call
g(You must call IFie inspecfor when ready) Date Ready:
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I, icensed conhactor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet,/B��)c or Rou�e No.� C' Zip Code
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Seclion No. Townshi�ame rn No. Range No.
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e�;�i c� g�, INC. CA00381
9100-22�Ti1 ST. W.. FG TN., MN 55024
Mailino AddresslContracfor or O�er Perfo[mino Inslo a'on)
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or o„mer r�orming �nsta�lation) 2��/�,[� 1, 1 Phorre No.
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STA7E BOARD COPY - 8EE INSTRUCTIONS ON BACK OF YELLOW COPY ,_ /