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REQUEST FOR ELECTRICAL INSPECTION �°'°
Minnesota State Board of Electriciry
7821 University Ave., Rm. S-128, St. Paul, MN 55104 �� ��
Phone (612) 642-0800 �
Other: ew Addn
Air Cond. Nf . Equip. Waler Hlr. Load Mgml. Ofher.
Dryer Range Elec. Heat Temp. Service
"X" above fhe work covered by this requesG Enter remorks in �his space ond on fhe back oi fhe whife copy only.
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Colculate Inspec�ion Fee - ihis Inspection Requesi will not be occepied wiihout the mrrect fee:
Other Fee # Servire Enhance Size Fee R Circuits/Feeders Fee
Mobile Home Park Stall O io 200 Amps 0 to 100 Amps Q,
Sfreet Ltg./Troffi< Sg. f+bove 200—Am s Above 100_Amps
Tmnsformer/Generator MSPECTOWS USE ONLV OTAL
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Boom
ihe elxviml Insmllafion described herein on the do
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' THIS INSTALLAiION MAY BE ORDy4e€D DiSCONNECT£D IF NOT COMPLETED WITHIN 18 MONTHS. �
OFFICE USE ONLY This request void 18 monlhs from volidafion date printed in Ifiis 6ox.
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PLEASE PRINT OR TYPE
Re�e-� Date� —� RougMin Inspectian requiredx� s� No Inspecrion Other Than Rough-In: � Ready Now O Will Gall
�Vou must call �he inspMOr when ready� Dare Reody:
I, (�'�icensed controclor ❑ owner hereby request inspection of the above electrical work o�:
Job Address (Sheel, Bax, or kou�e NoJ Ciy Zip Code
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Secfion Na. iownship Name or No. Range No. Fire No. Counry
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iry Name� Conhaciar Licensa No. Mosrer Lic Na �%om Flec�
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STATE BOAHD COPY - SEE INSTflUCTIONS ON BACK OF YELLOW COPY