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Home � � Duplex
Commercial Industrial
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Calculate Inspection Fee - This Ins i
Other Fee
Mobile Home Park Stall
Street Ltg./Traffic Sig.
Transformer/Generator
Sign/Oudine Lig. Xfmr.
Alarm/Remote Conhol
REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612) 642-0800
Other: New
Farm Remod
Water Htr. load Mgmt. Other:
Elec. Heat Temp. Service
requesl. Enter remarks rn this space and on the back of tj
C,�Q�ii— .
ion Request will not be accepted without the correct fee:
# Service Entrance Size Fee # Circuits
0 to 200 Am s 0 to 100 A
Above 200 Am s Above 100
INSPECTOR'S USE ONLY
fhe
Date
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copy only.
Fee
� �a _ 2 ��.- c
Inves�igative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
.. OFFICE USE ONLY This request void 18 months from validation dafe printed in this box.
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* D 8 4 5 0 9 4 2* p�v��
PLEASE PRINT OR TYPE
Request Date Rou h-in ins on r uired2 ❑ Yes
,�� g pecti eq ❑ No Inspection 01her Than Rough-In; Ready Now ❑ Will Call
O' (You must coll the inspector when'ready) Date Ready:
I, icensed conhactor ❑ owner hereby request inspection oF the above elechical work at:
Job d ss (Sfreet, Box, or Ro No.� � Cily�,�-� Zi�
Secfion No. Township Name w No. ange No. Fire No. Couny _ /
� Power Supplier
I�
DEPENDABLE ELECTRtc
� s I�aDb9�°'R�� P��s
Ceon Rapids, Mi� 5543
rrized SignaNre (Conf 1 or Owner PerFon
)Ol A-11 8/96
Phone No.
Conhacror
Insrollafio � — ' � `•" Phone No.
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COPY - SEE INSTRUCiIONS ON BACK OF YELLOW COPY