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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 •
Other: New Addn
Farm Remod
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of ihe whiie copy
�,,t,'c,� � i`�I �
cula nspection Fee - This Inspection Requesf will noi be accepied wifhout the correc► fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �
Sign/Oudine ltg. Xfinr.
Alarm/Remote Conhol
$wimmin9 POO� 1 hereby cerfify that I inspacted fhe elechical installation described herein on the dates stafed
Invesfigative Fee – ..�. 't�: � --.�____ �_ �—� `
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE U ONLY This request void 18 months kom validafion date prinfed in this box.
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* � 4 �a 8 � 8 3 L* PLEASE PRINT OR TYPE ���
Requesf te Rough-in inspecfion required8 ❑ Yes No Inspecfion Orher Than RougMn: Ready Now ❑ Will Call
' (You musf call the inspecfor when ready) Dafe Ready:
I, licensed conhactor ❑ owner hereby request inspection of the above elecfrical work at:
Iob Address �Street, Box, a Roufe No.) City Zi Code
P
I I cv� N u s� `aQ
Secfion No. Township Name or No. Range No. Fire No. Couny_
� Power Supplier
Elechical Confracfor ((
Harri
n��i�� naa �c �
Address
n Electric, I
or Owner Performing Insfallafion�
for License No. Masfer Lic.
CA00808
lden Valle�, MN
.� � Phone No.
r r - - � �-+ni—�
COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPv