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RE�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electriciry
1821 University Ave., Rm. 5-728, St. Paul, MN 55104
Phone (612) 642-0800
Ap�. Bldg. Olher: e Ne
Form � Re
Woter Htr. Load Mgml. pther;
Elec. Heaf Temp. Servi<e
this request. Enter remarks in this space and on the
Calculofe Inspeclion Fee - 7his Inspecfion Reques/ will not be omep�ed wifhou� the mrred fee:
Other Fee # Service Entrance Size Fee # Circuits
Mobile Home Pork Stall 0 to 200 Amps 0 to 100 P
Sheei Lfg./Troffic Sig. Above 200—Am s Above l OC
Trnnsformer/Generafor MSPECTOR'S USE ONLY
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Fee
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�°"""""� '��' I he,eb cerci rhm I m: cred ihe elecrc��d ��smllmion deu��bed herein on ihe dares siared
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Imesfigative Fee � ��j —� � �
THIS �NSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
I� IIIII II III II III IIIII II� II�I III� I�II OFFICE USE ONLY This reqoest void 18 mont�m voBda�ion da� nled in�6ox.
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PLEASE PRINT OR TYPE
Re uez.Dare Rough�in insoection required? �� Na Impeciion Other ihon Roughan: ❑ Ready Now�EvlF
`(� `- e �Yoo mus� coll ihe inspxmr when ready) Daie Ready:
I„ censed conlmcror ❑ owner hereby request inspecfion of Ihe above electrical work af:
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STATE BOARD
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