P - 80831��3��-867 �
Home Duplex
Commercial Industrial
Air Cond. Htg. Equ
Dryer Range
"X" above the work covered 6
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Calculale Inspection Fee - This Inspe
Other Fee
Mobile Home Park Stall
Street Ltg./Traffic $ig.
Transformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Pool
irrigation Boom
Soeciallnso A �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Farm
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on
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New
Remod
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of the white copy only.
�tion Request will not be accepted wi►hout fhe correct fee:
# Service Entrance Size Fee # Circuits/Feeders
0 to 200 Amps 0 to 100 Amps
Above 200 Am s Above 100 Ai
INSPECTOR'S USE ONLY TOTi
herein on the
Fee
I Investigative Fee' '� Y V �....�� (� �� �,%l ��%
THIS INSTALLATION MAY BE 9RDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months kom validation dale printed in ihis box.
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* 0 8 3 6 8 6 7 2* 7�0 �
PLEASE PRINT OR TYPE
Requesf Date Rovgh-in inspecfion required? ❑ Yes No Inspech:on Olher Than Rougffln: ❑ Ready Now ill Call
� �� (You musf call the inspecfor when ready) Dafe Ready:
I, �licensed confractor ❑ owner hereby request inspection of the above elechical work at:
Jo Address (Sfreet, Box, or Roufe No.) City � Zi od
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Secfion No. Township Name or No. Range No. Fire No. Counly � n �
Occupant
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Ce� t�
or vwne� rerrormmg msmnarwn�
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cror or Ow r ming InstallaKon� I
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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