P - 81549���-418 �
REQUEST FOR ELECTRICAL INSPECTION ��
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �;
Phone(612)642-0800
Other: New Addn
� Commercial Industrial Farm ' emcd Re
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this rPquest. Enter remarks in this space and on the back of the white copy only.
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Colculate Inspection fee - This Inspection Requesi will not be accepted withoui the correcf fee:
Other Fee # Service Entranc Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 0 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Trans{ormer/Generator INSPECTOR�S USE ONLY TOT
Alarm/Remote Control �! `�" ���
Swimming Pool
I hereb certi tha� I ins ecfed the electrical installation described here'm on tha dafes sfaied
Irrigation Boom Ro�yh-i� Da
Speciol Inspecti ��'{ '��
9 Final , _ Dat� �. �. O/
Investi ative Fee pc
THIS iNSTALLATtON MAY BE ORDERED DISCONMECTED IF MOT COMPlETED WITHIN 18 MONTHS.
� OFFlCE USE ONIY This requesf void 18 monfhs from validafion dafe prinfed in ihis box.
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Section No.
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PLEASE PRINT OR TYPE
� Rough-in inspection required? es ❑ No Inspecfion Other Than Rougirin: ❑ Ready Now � Will Call
(You must call fhe inspector when ready) Date Ready:
I contractor ❑ owner hereby request inspection of the above electrical work at:
y` Box, or Roufe No.) City w - p Zip Code
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vnship Name or No. Range No. Fire No. Couny
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Mailing Address (Conhaci
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Address
Conhacfo License No.
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STA7E BOARD Y- SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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