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REQUEST FOR ELECTRICAL INSPECTION ;,ar�� ...
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Commercial Industrial Farm
Air Con Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on
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Cakulate Inspection Fee - This Inspection Request will not be accepted without fhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/�eeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 ro 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TO��1�'D
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I certi that I ins ihe
Irrigation Boom RougMn
Special Inspection
Investigative Fee �
described herein on Ihe da
Date
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months irom validafion date printed in this box.
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Requa��C q� Rough-in inspection required? ❑ Yes No Inspection Other Than RougMn: Ready Now � Will Call
(You must call the inspector when ready) Da�e Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
ob dress (S BOx, 04 Roule1No.) t � Ciry . Zip Code
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Seclion No. Township Name or No. . Range No. Pire No. C y
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I Power
Ele�i�116�n1r�c�r {�npd� IJ�� t 1 1 C� I Il C. Conh�CCl�i �� �8 AAaster lic.. No. �Plant Eleci.
"�'�'�ul�'�d�'�'PY'��"°0l�rth, 301, Golden Valley 55427
4-3300
STATE BOARD COPY - SEE I CK OF YELLOW COPY