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REQUEST FOR ELECTRICAL INSPECTION -
Minnesota State Board of Electricity
1821 University Avenue Suite S-12$ Saint Paul, Minnesota 551042993 - -
(651) 642-0800 www.electricity.state.mn.us `'�''
Home Duplex Apt. Bldg. Other: New
Commercial Indusirial Farm Remod
Air Condifioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this 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 accepted withouf 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. / Troffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT� �.,
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimminq Pool
that 1 insoected the elechical installation described herein
Dafe
� � Investigative Fee � � � (S { F� "" �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
—s�� OFFICE USE ONLY This request void 18 monfhs from validation date prinfed in this box.
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PLEASE PRINT OR PE
Request D Rougfrin inspection required8 ❑ Yes o Inspeclion Other Than RougMn: ❑ Ready Now Will Call
�"'ll �� You must call the inspecror when ready Date Ready:
I,�licensed contractor ❑ company ❑ owner hereby request inspection of the above elecfrical work at:
Job Address ($¢eet, B or Jioufe No.� Ciy Zip Code
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Section No. Township Na�r No. Range N� Fire No. County ��
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Power Supplier ' � ' Address
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� EI frical Conhacfor / Company Na e
ailing A dress �Confracfor, Company or. er Pe rming Insf Ilafi�
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Authorized a ture IC tractor. Co�anv or e ina Insh
Phone No.
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No. Master Lic. No. (Mant Elecf. Only)
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1�-i, v�. 55�3
Phone Number
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY