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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 -
Phone(612)642-0800
Apt. Bldg. Other: New Addn
Farm emod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the 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 Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
T�ansformer/Generatoc INSPECTOR'S USE ONLY TQ�A�' ��
Sign/Outlioe Ltg. Xfmr. /1.,� �yys�,v � 5
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Alarm/Remote Conhol
Swimming Pool
I hereb cerli ihatl ins ed the elechical installation described herein on the dates sfafed
Irrigation $oom RougMn D
Special lnspection ' 0� 2 2 Q
Finol
Investigative Fee �-
THIS INSTALLATION MAY BE ORDERED DISCONNE _ D IF NOT COMPLETED WITHIN 18 MONTH .
OFFK:E USE ONLY This request void 18 monihs from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request /� Rougf�in inspection required$ - Yes ❑ No Inspecfion Other Than RougMn: ❑ Ready Now ❑ W�II Call
��/ �� Z-(� �You must cull the inspecfor when eady� Dafe Ready: -
I, licensed co�nhactor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Roule No.) Ciry � Zip Code
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Phone No.
Conhacror (Company Name) Q Conhacror License No. Master Lic. No. �Plant Elecl. Only�
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�ddress (Conhactor w Owner Performing Installation)
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d ign ture (Conh ror or ne e rming Insfaflafion) ` ��-� � Phorre No.
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4-11 8/96 S7ATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY