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� Home Duplex
Commercial Industrial
Air Cond. Htg. Equi
Dryer Range
"X" above the work covered b
REQUEST FOR ELECTRICAL INSPECTION °1e
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �i
Phone(612)642-0800
Apt. B1dg. Other: �' S'� New Addn
Farm Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. $ervice
request. Enter remarks in this space and on ihe back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Ar
Transformer/Generator INSPECTOR'S USE ONLY , TOT�
Sign/Outline Ltg. Xfmc
Alarm/Remote Confrol
Swimming Pool
�s v
I hereb certi �at I ins cted the electric ' stallation described herein on the dates stated
Irrigation Boom Ro�9h-I� a��
Special Ms i '� — �� _ n
Investigative ee �f8 p jce�C.,
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1 MONTHS.
OFFICE USE ONLY This roquest void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rou h-in ins ction r uired$ Yes
g pe eq ❑ No Inspecfion O�er Than RougMn: ❑ Ready Now Will Call
/D� ��t 99 (You mvst call fhe inspector w en ready� Date Ready:
I, ❑ licensed conhactor�owner hereby request inspection of the above elecfrical work at:
Job A ress (Sh f, BcvcpcRoute No.) City Zip Code
�S�JA��s v, c� .� �l1�a ss-��a
Seclion No. Township Nam� N� Rang� � Fire No. Coun
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� ' Phone No.
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No. (%ant Elect.
Owner PerForming Insfallafion) � Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY