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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: OU c New Addn
Farm � � J� Remod Re air
ip. Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
OtheF Fee # Service Entrance Seze Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Si . Above 200 Am s Above 100 Amps
Transformer/Generator iNSPeCroR'S USE ONLY TOTAL�j ��
c___ /�_.1�__ i._ vL_
Swimming Pool I hereb certi that I ins ted the electrical installafion described herein on the dates stafed
Irrigation Boom RougMn
Special Inspection �� , � ��Z
Final ,O s ,� Q S
Investigative Fee � �LG. � J�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED 1 NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monihs (rom volidafion daTe prinied in this box.
I IIiI II liI ll lll ll l l! II III I I IN ���� n�
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* 0 8 0 2 3 1 2°� L���C%
PLEASE PRINT OR TYPE
Request D Rough-in inspection required? Yes ❑ No Inspection O�er Than RougMn: ❑ Ready Now �II Call
� � (You musf call fhe inspector when ready) Date Ready;
I, ❑ licensed contractor �owner hereby request inspection of the above elecfrical work at:
Jge Address� �x, Route No.) � Q� ����� ZiP C ��
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Secfion No. Townshi�Ncyne or No. Range No. ` Fire No. County /J _�
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(Company
or
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License No. Mastet Uc. No. 1Plonf Elecl. C
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY