P - 803330=892-562 �l
REQUEST FOR ELECTRICAL INSPECTION �T"E
Minnesota State Board of Electricity �'
1821 Universiry Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 �i
(651) 642-0800 www.electricity.state.mn.us
Home Duplex Apt. Bldg. Other: New Ad�
Commercial Indusfrial Farm Remod ReF
Air Conditioner Hfg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" ab the work covered by this re uest. Enter remarks in this s ace and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accep►ed without the correcf fee:
Other Installations Fee #$ervice Enirance Size Fee # Circuifs / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL „
Sign / Outline Ltg. Xfmr. `y �
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Alarm/Remote Control
Swimming Poo)
I hereb certi that I ins the electrical installation described herein on the dates stated:
Irriqation Boom a,.,,..ki., n..,e
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required2 ❑ Yes ❑ No Inspection Ofher Than Rough-In: Ready Now ❑ Will Call
_�� �' a"�,� � � You must call the inspecror when ready Dote Ready:
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
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1ob Address (Sheet, Box, or Route Qlo.) / � � City _ / f Zip Code
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No. Township Name or No. Range No. Fire No.
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upplier ' �� Address
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I Cpnhacfor /,Company Npme , Contmctor Licen<.
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Address �Confracfor, Company or Owner Pe orming Installation)
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ed Signature (Contractor, Company or Owner Performing Insfallation)
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� -� ��9 STATE BOARD COPY �
Phone No.
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY