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REt�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
New
/ Commercial Industrial Farm Remod
Air Co Htg. Equip. Water Htr. Lood Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ►he work covered by ihis request. Enter remarks in this space and on ihe back of the white copy
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Calculate Inspection Fee - This Inspection Request will not be accepted wifhout the correct fee:
Other Fee # Service Entrance Size Fee Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR's USE ON�Y TOT}4L
SignJOuiline Ltg. Xfmr. �
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins ted the elechical installalion described herein on the dates stah
IrriQation Boom a,,,,.,�„ o�
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THIS INSTALLATION MAY BE ORDERED DIS D IF NOT COMPLETED WIT 18 MONTHS.
OFFlCE USE ONLY This roquest void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Dofe Rough-in inspection required? ❑ Yes ❑ No Inspection 01her Than RougMn: Reody Now � Will Coll
�'�l' �� (You must call the inspecror when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job d�eu (Sheet, Box, or R No.) Ciry Zip Code
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o���po�r
Power Supplier
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License No.
No.
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or uwner rerrorm inuwWnon) A A�� � r.
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TE B AR OP - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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