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"X" above the work
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RE(�UEST 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 ddn
Farm Remod Re air
ip. Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
�x this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspeciion Request will not be accepted without the correc► fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps to 100 Amps �
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAI� �'�
Sign/Out�ine Ltg. Xfmr. / �
Alarm/Remote Conirol
Swimming Pool
I hereb certi that I ins ted ihe elechical insfallation described herein on the dates stated
Irrigation Boom Ro�gMn �°1e
Special Inspecti pa�
Finol � ��!'1 dQ
Investigative Fee ^"'
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COIWPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion date prinfed in fhis box.
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Requesf Dafe��� � Rough-in inspecfion required? ❑ Yes o Inspecfion Other Than Rough-In� dy Now ❑ Will Call
(You must call the inspector when ready) Dafe Ready:
I, �Ti2ensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Ad�s� eet, Box, or oute No.�� /\� � City � l `� /� Zip Code
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Secfion No. Township Name or Range N Fire No. County
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Occupanf Phone No.
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Power Suoolier Address
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dress Confracfor or Owner Performing Installafio
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SipnaNre �ConhaG�or or Owner Performi p I sfa
Conhacfor License No.
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Masfer Lic. No.
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