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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ��:
(651) 642-0800 www.electricity.state.mn.us '���
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Condifioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by �his reques�. tnter remarks in this space and on the back ot the whrte copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
er Installations Fee # Service Enfrance 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 TOT
$ign / Outline Ltg. Xfmr. Q� �
Alarm/Remote Control
�� ����������a � I hereb certi fhat I ins ed the electrical installation described herein on the dates stated:
Irrigation Bo Rough-In Date
Special Inspection
Invesfigative Fee F�nol Dar�� 2 o rQ�
THIS INSTALLATION MAY BE ORDERED DISC CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf fe Rough-in inspection required$ ❑ Yes No Inspecfion Other Than Rough-In: eady Now ❑ Will Call
��� � You must call fhe inspector when ready Dafe Ready:
1, �licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address ISheet Box, or Route No.l _ . CiH i Zip Code
I Power
� Mailing
Name or No.
� S� ���
nfractor / Company Name �'
�� �
�ess (Contractor, Com any or Owner
� Z ��
ure IContmcror, Compgy� or O�
2 5/�99 STATE BOARD COPY
Range No. � Fire
Insfallafion)
Phone No.
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No. Master Lic. No. (Plant Elect. Only)
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Phone Number
(16 -- l�l
SEE INSTRUCTIONS ON BACK OF YELLOW COPY