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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
Apt. Bldg. Other: New Addn
Farm Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of ihe whiie copy only.
Calculate Inspection Fee - This Irispection Request will not be accepted wiihout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/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 iNSaeCTOR'S USE ONLY A
Sign/Outline Ltg. Xfrtir.
Alarm/Remote Control `�
Swimming Pool
I hereb certi that I ins the electrical insfallation deuribed herein on ihe dafes stated
Irrigation Boom � Rough-In . Dare
Special Inspecti
Final Date. � �
Investigative Fee -- ?
THIS INSTALLATION MAY BE ORDERED DISCO CTED IF NOT COMPLETED WITHIN 18 MONTHS.
�� OFFICE USE ONLY This request wid 18 months from validation date printed in this box.
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LEASE PRINT OR TYPE
Requesf Rough-in inspecfion required$ ❑ Yes No Inspecfion Other 11�an RougMn: Ready Now 0 Will Call
(You must call the inspecfor when ready) Date Ready:
I, lice sed c nhactor ❑ owner hereby request inspection of the above electrical work at:
Jo Address (Sheet, , r� o.� � n N�„ �� Cdy ��� Zi �
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Secfion No. Township Name o No. Range No. a Fire No. County
Occupanf
Power Su�
Phone No.
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onhacroAiCiii��� Conh r' n o Masfer Lic. No.
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dress (Controcrosoj n �5 0��4�
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Signaiure (C hac r or orming nsfa Phone No.
1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY