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Home Duplex
Com ial Industrial
Ai Htg. Equi
Dryer Range
"X" above the work covered b
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: New Addn
Farm Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service '
request. Enter re � s' this space and on the back of the white copy only.
� /Y/ �.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stoll 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Ar
Transformer/Generator INSPECTOR'S USE ONLY TOT�
Sign/Outline Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Pool
I hereb certi that I ins fhe elechical insfallation dexribed herein on the dah
Irrigation Boom RougMn Dore
Special Inspectio : f
` F' 1 D
Fee
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Investigative Fee �) ��O °� --/� •• �3
THIS INSTALLATION MAY BE ORDERED DIS CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Reque t Dafe Rough-in inspecYion required? ❑ Yes
.^` �� ❑ No Inspec�ion Other Than RougMn: Ready Now � Will Call
� �You must call the inspeclw when ready) Dafe Ready:
I, licensed contractor ❑ owner hereby request inspection of the above elecfical work at:
Job Address (Sheef, Box, or R No.) Cily Zip Code
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Seciion No. Township Name or No. Ranqe No. Fire No. Cou o� .
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Power Suppier °
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Elechical Confractor (Company Name)
apids Bivd. KW
Phone No.
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� � Master Lic. No. (Pbnl
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Phone No.
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- SEE INSTRUCTIONS ON BACK OF