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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity �'
1821 University Avenue Suiie 5-128, Saint Paul, Minnesota 55104-2993 +�����
(651) 642-0800 www.electricity.state.mn.us "�'
Other� New Addn
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enter remarks in this space and on the back of the white copy
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Calculate Inspection Fee - This Inspection Request will not be accepied without the correct fee:
Other Installations fee # Service Enhance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT
Sign / Outline Ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins ted the elechical insta�lation described herein on the dates stated:
Irrigation Bo Rough-Ir, Dare
� Investigative Fee � � �'� i ��'7 ���
THIS INSTALLATION MAY BE ORDERED DISCONNE ED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date prinfed in this box.
I��I�������Ill�lll�f I���IIII�I�����I� • , ��p "�
* 0 8 9? 8 5 7 9 * io�04
PlEASE PRINT OR TYPE
equest Date Rough-in inspecfion required? ❑ Yes Inspecfion Ofher Than Rough-In: eady Now ❑ Will Call
1`--' �—�� You musf call the inspector when ready Date Ready:
, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
b Address (S}r et, Bo or Route No.) City Zip Code
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Section No. I Township Name or No.
Address
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2 5/�999 STATE BOARD COPY
Phone �� � � ���
�tractor License No. Master Lia . Plant Elect. Only� .
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Ph ne Number
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY