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Home Duplex
Commercial Industric
Air Cond. Htg. Eqi
Dryer Range
"X" above the work covered
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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 -
Phone (612) 642-0800
Other: New Addn
Farm
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
s request. Enter remarks in this space and on the
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Calculate Inspection Fee - This Inspection Request will no► be accepted without the correct fee:
Other Fee # Service Entrance ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
Sfreet Ltg./TraFFic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR•S usE ON�Y T L
D
Sign/Outline Ltg. Xfmr. Ors
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins ected the elecfrical installation described herein on the dates stofed
Irrigation Boom Rough-In Da�e
Speciallns ��
Finol D
Investigative Fee t� �—
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation dafe prinfed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Da Rou h-in ins ion r uired8 ❑ Yes
g pecY eq �lo Inspection Other Than RougMn: �Rnady Now ❑ Will Call
� �� �D �You must call the inspector when ready) Date Ready:
I, '�licensed contractor ❑ owner hereby request inspection oF the above electrical work at:
Job Addr� eet,�x, or Roy(e No.) Ciy • Zip
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Section No. Township Name or No. Ranste No. Fire No. CounN _ .
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ON BACK OF YELLOW COPY