P - 79504�02-328 �
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:
Commercial Industrial farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:�
Dryer Range Elec. Heat Temp. Service
"X" a ve the work covered by this request. Enter remarks in this space and on
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Calculate Inspection Fee - This Inspection Reques il/rY6fQ��p� i out
Other Fee # ance Si e Fee
Mobile Home Park Stall to 200 ps
Street Ltg./Traffic Sig. A 0 m s
Transformer/Generator _ __ iNSPeCroR'S USE ONLY
New
Remod
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R/fh — "the correct fee.
# Circuits/Feeders
0 to 100 Amps
Above 100 Ai
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Addn
Fee
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ed the electrical installation described herein on the dares stated
Irrigation Boom Rough-In �re
Special Inspection
Investigative Fee F��ol 'U�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validafion dafe printed in this box.
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Request Da Rough-in inspeclion required? ❑ Yez No �nspecfion Ofher Than RougMn: ❑ Ready Now Will Call
��i (You musf call the inspecfor when ready) Dafe Ready:
I, ❑ licensed contractor �] owner hereby request inspection of the above electrical work at:
lob Address �Sheet, B c, or Route No.) Ciy Zip Code
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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