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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 oniy.
Calculate Inspection Fee - This Inspection Request will not be accepted wifhout the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park $tall 00 Amps � 0 to 100 Amps
Sireet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T��� t� `"�
SignJOudine Ltg. Xfmr. , �J
Alarm/Remote Control
Swimming Pool � her ceAi SVmt I ins ed the electrical installation described herein on the datas stoPad
Irrigati4n Boom Ro�Mo - f Z� —�'
Special Inspect'
' Firal ,
Investigative f � ""�'
THIS INSTALLATION MAY BE ORDERED DiSCONNECTED IF NOT COMPLETED WI HIN 18 MONTHS.
OFRCE l�E ONLY This roqu�f wid 1 S monlhs Irom validafion date printed in this box.
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(IIII I��II �II�I IIII� II I IIIII I�II) �� IIAI l. ,.
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* 0 5 6 6 9 9 6 5�K PLEASE PRINT OR TYPE
Requesf Rou Ifin ins tion r uired2 � Yes
g pec eq ❑ No Inspection Other Than Rough-In: ❑ Ready Now Will Call
�.Q, � �You must call the inspec�or when ready) Date Ready:
I, licensed confractor ❑ owner hereby request ins ection of the above electrical work at:
Job Address ��t, Box, or o.� Ciy �� Zip Code
3
Seclion No. Township Name or No. Range No. Fire No. Co
QRyippnf � A f � Phone No.
I Contractdr (C��y�jJ��TRIC, INC. CA003$�Conbacror License No. I N
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310G-22bTN ST. W., �.a TU.. �;?�1 5502�1.
Addreu (Contrac r or Owner Pe ing Ins �
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ed SignaNre ( onhocMr or er Performi sfallation) � � PI
IA-11 8/96 �7pTE BOARD COPY - SEE INSTRUCiIONS ON BACK OF YELLOW COPY