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REGIUEST fOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-�800
New
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Commercial Industrial Farm Remod Re
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered b this request. Enter remorks in this poce and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Requesi will not be accepied without the correct fee:
Other Fee # Service Entrance Size Fee # CircuitsJfeeders 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/Generator INSPECTOR'S USE ONLY TO�Aii� /
SianlOutline Lta. Xfmr. • __J
� Pool
Boom
fJ �4�—
that I ins ted the e�echical installation described herein on the daMs stated
Dafe
Speciallnspe ' '
Final Da G
Investigative fee — D'
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 monfhs from validation date prinfed in this box.
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* 0 7 1 9 7 2 0 5* '� 7`� 7
EASE �RINT OR TYPE
Requesf Dafe Rough-in inspecfion required$ ❑ Yes o Inspection Other Than RougMn: ❑ Ready Now i Call
J� v (You musf call fhe inspecfor when ready� Dafe Ready:
I, 'censed contractor ❑ owner hereby request inspection of the above electrical w rk at:
Job, ddress (SMe�„�ox, or Route N City _� Zip Code
Name
Phone No.
No.
� Mailing Ad¢r� o %r or Owner
v
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STATE BOARD COPY - SE NSTRUCTIONS ON BACK OF ELLOW COPY