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Home Duplex
Commercial Industrial
Air �I . Htg. Equi
Dryer Range
"X" above the work covered b
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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
Apt. Bldg. Other: New
farm Remod
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks " this spac and on fhe back of ihe white
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Calculate Inspection Fee - This Inspection Request will noi be accepied without the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./TrafFic Sig. Above 200 Am s Above 100 Amps
Transformer/Generaior INSPECTOR'S USE ONLY TOT L
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins ted the elechical installation described herein on fhe dafes sfated
Irrigation Boom Roughan Dare
Special Inspecti
Final D�ye �?
Investigative Fee �t-�--- e<
THIS INSTALLATION MAY BE ORDERED DISC ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 1 S monfhs from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Dale Rough-in inspecfion required$ ❑ Yes Inspecfion Other Than RougMn: Rea ❑ Will Call
Q.� `� q �You must call fhe inspecfor when ready) Date Ready: �'.� f���
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address �Sheet, Box, q Route No.� ,� �_ .. Zip Code ,
Secfion No. I Township Name or No.
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Power Suoolier
Conhacfor Co pany Name) ,
1 a C� �Cm I--I�t� . �:
Phone
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ofu onhactor o ming Installati � o A �
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� OPY - SEE INSTHUCTIONS ON BACK OP YELLOW COPY