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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
!( Home Duplex Apt. Bldg. Other: New
Commercial Industrial Farm Remod
Air Cond. fg. Equip. Water Hh. Load Mgmt. Other:
Dryer ange � Elec. Heat Temp. Service
"X" above the wor 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 without the correct fee:
Other Fee # Servi e Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT �
Sign/Outline Ltg. Xfmr. � „(
Alarm/Remote Control vt�EJ
Swimming Pool
I hereb certi that I ins fhe eleclrical installation described herein on the dates slaled
Irrigation Boom Ro�Mn
Special Inspection ` �-'�` " � — ��
Final
Investigative Fee yi'� -+c
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request wid 18 months 6om validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf DateQ Rough-in inspeclion required? Yes ❑ No Inspecfion Other Than RougMn: ❑ Ready Now Will Call
�' p� /� � 0 (You must call the inspec�or when ready) Dafe Ready: �
I, �licensed confractor ❑ owner hereby request inspection of the above elechical work at:
Job Address �Sheef, Box, or Roufe No City Zip Code
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Sec�ion No. Towns ip Name c�No. Ranpe No. Fire No. Counly
Occupant
Power Supplier
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Elechical Controctor (Company
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Signafure (Conhacfor or
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Phone No.
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Conhactor License No. Master �ic. No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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ne No.
/2 � 88-016