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REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
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Commercial I dustrial Farm Kemod Ke air
Air Cond. Htg. Equip. Water Htr. Load M mt. Other:
Dryer Range 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.
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�alculate Inspection Fee - This Inspection Request will nof be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps -�
$ireet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/C'ienerator INSPECTOR�S USE ONLY TO
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted fhe elechical installation described herein on the dates staled
Irrigafion Boom Rough-In Dare
Special Inspecfion
Fina) Date a 2 2�g
Investigative F . l
THIS INSTALLAT{ON MAY BE ORDERED DI NECTED {F NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE �llY This roquest void 18 months 4rom validation dafe prinied in ihis box.
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LEASE PRINT OR TYPE
Requ st Date a� Rough-in inspecfion required6 ❑ Yes No Inspecfion Ofher Than RougMln: d Now ❑ Will Call
�v � (You musf call fhe inspecfor when ready Dafe Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lo A dress �Street Box, or Roufe No. � City Zip Code
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Section o. Township Name or No. Ranpe No. Fire No. County
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�Company Nq e .
nhacfor or Owner Performion.{nsfallafic
License
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STATE BOARD COPY - SEE INSTRUCTiONS ON BACK OP YELLOW COPY