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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
Other: New
Industrial Farm Remod
Htg. Equip. Water Htr. Load Mgmt. Other:
Range Elec. Heat Temp. Service
overed by this request. Enter remarks in this space and on
copy
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
$treet Ltg./Traffic Sig. Above 200 Am s Above 100 Amp:
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. �
Alarm/Remofe Control
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: )�la ;
Fee
Investigative Fee �' (J —
THiS INSTQLLATION MAY BE ORDERED DISCONNEGTED IF NOT COMPLETED WITHIN 18 MO HS.
OFFICE U8E OPILY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required? ❑ Yes Inspection O�er Than Rough-In: ❑ Ready Now ill Call
• q� �You musT call fhe inspecfor when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Bo �or Route No.) Cily Zip Code �. �
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Secfion No. 7ownship Name or o. Ranae No. Fire No. ntv _
I Power
Elecfricapl C�o�nfr�a�cto�r,
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Phone No.
License No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY '