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REQUEST FOR ELECTRICAL INSPEGTION ���'�`� �
Minnesota State Board of Electricity %3
1821 Universiry Avenve Sui�e S42$ Saint Paul, Minnesota 55104-2993
(651) 642-080o www.electricirystate.mn.us ���
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y fhi> request Enter remorks in this spac
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Fee - ihis Inspection Request will no/ be
# Service En�mn<e ' Fee
0 to 00 Am �
Above 200_Amps
INSPECTOR'S USE ONLY
on
copy
� without the correct fee:
Cirails / Feeders
0 ro 100 Amps
Above 100_Amps
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Irrigalion Boom a� po�qh�io �- °a'e
Special Inspection F��ol . o��P �_ Q Z
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 16 MONTHS.!_
OFFICE USE ONLY This reqoesr vold 18 momhs fmm val�dalian dare prinred In �hls box.
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Reqves� Dme Rougl�ln'mspenion required2 ❑ yes Inspetlion O�her Than Rough In: ❑ Reody Now 0 WIII Call
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I, �ensed conhocfor ❑ compony ❑ owner hereby request inspeclion af ihe a6ove eleciricol work at
Job Address (Sireet, Box, or kouk No � C Zip Cade
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Commctor License No.
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