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RE(�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
New
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Commercial Industrial Farm Remod e
Air C Htg. Equip. Water Htr. Load Mgmt. Other:
ryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calcula►e Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps , 6
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
TransFormer/Generator INSPECTOR'S USE ONLY TOT �
Sign/Outline Ug. Xfmr.
Alarm/Remote Control
Swimming Pool
I herebvi certi(v that I inscected the electrical installation described herein on the dotes stated
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Invesfigative Fee .�
THiS INSTALLATION MAY BE ORDERED DISCONNECTED IF N07 COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf wid 18 monfhs from validation date printed in this box.
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I III II 1lI�II II fif � f� i i�l
* 0 7 0 6 5 8 4 0* ��b
PLEASE PRINT OR TYPE
eque fe Rough-in inspecFio� required2 ❑ Yes o Inspection Other Than RougMn: Now � Will Call
' (You must call the inspector when ready) Date Ready:
licensed contractor ❑ owner hereby request inspection of the above electrical work at:
�b A ress (Sheet, Box, or Royfe No.l _ . 'N � . i Zio Code
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Section No. Towns ip Name or No. Range No. Fire No. Cou t_
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O f � ���� Phone No � r�/'� —
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Power Supplier Addreu
EI fr' al Conhacfor (Company Name� - Confr License No. Nwster Lic. No. �Pbnt Elect. Onlyj
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Mailing Address �Conhact r or Owner Perfor ing Instal ion) � � �^
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uthorized Si er Pe rming Insfallafion) hone No.
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B-OOOOlA-11 8J96 TE BOARD COPV - SEE INSTRUCTIONS ON BACK OF YELLOW COPY