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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
Other: New
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Commercial Industrial Farm Remod Re
Air Cond. Htg. Equip. Wafer Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this s ace and on the back of the white copy only.
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Calcufate 1 spection Fee -�is Inspection Request will not be accepted wifhout the correct fee:
Other Fee # $ervice Entrance S' e Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to Amps ��� , 0 to 100 Amps ,�
Street Ltg./Traffic Sig. Above 200 m s Above 100 Amps
Transformer/Generator INSPECTOR�S USE ONLY T�L,r, _�
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Sign/Oudine Ltg. Xfmr. iY
Alarm/Remote Control
- ��� �° �-- 1 hereb certi that I ins Ifie eleclrical installation described herein on the dates stated
Irrigaiion Boom RougMn Date
Speciallnspectio (.
final Dale �� y
Investi ative Fee ^
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITFIIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs (rom validafion dafe prinfed in fhis box.
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PLEASE PRINT OR TYPE
Reques Date Rough-in inspeclion required$ ❑ Yes o Inspecfion Olher Than RougMln:
I� �'" � g (You must call the inspector when ready) pote Reody:
I, �licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
1ob r (Streer, Box, Route o.) C;y�
03 ,��is T�� o
Seclion No. Township Name or No. Ranpe No. Fire No. CounN
Occupanf
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Name) Conkacfor Licen:
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Now ❑ �II Call
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4ddress (Conhacfor or (�wnerPerforming Insfallafion� i
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A-1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY