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Home Duplex
REC�UEST FOR ELECTRICAL I�SPECTION
Minnesota State Board of Electricity "
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
New
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em
Commercial ndustnal Farm
Air 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
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Calculate Inspection Fee - This Inspection Request will not be a epted without the correct fee:
Other Fee # Service Entrance Size Fee Circuits/Feeder.
Mobile Home Park Stall 0 to 200 Amps to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 A
Transformer/Generator INSPECTOR'S USE ONLY TOl
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Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool �
that I ins cted the electrical installation described herein on the da
Date
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copy only.
Fee
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Investiqative Fee �
THtS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monihs from validafion date prinfed in this box.
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PLEASE PRINT OR TYPE
uesf Date Rough-in inspection required? ❑ Yes
�/�, t/j.� ❑ No Inspection Other Than Rough-In: Ready Now � Will Call
7 7 �You must call the inspector when ready� Date Ready:
icensed contractor ❑ owner hereby request inspection of the above electrical work at:
ddress �Streef, Bo No.) .. City Zip Code
i� No. To�ship Name r No. Range No. Fire No. F Counly s ��
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1 , Phone No.
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Power Su �er p , �
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Electncal Confractor (Company Name)
DEPENDABL£ EIECTRIC. I{V�,
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C�on Rapids. MN 55433
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STATE B COPY - SEE
MasTer
Phone No.
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