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� REQUEST FOR ELECTRICAL INSPECTION -
Minnesota State Board of Electriciiy
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-OS00
Apt. Bldg. Other: New Addn
Commercial indusfrial farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by �his request. Enier remarks in this space and on
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Remod
the whiie copy only.
Calculaie Inspection Fee - This Inspection Request will not be accep►ed withoui 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 INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool
I hereb certi thaf 1 ins ted fhe elechical ins�c
Irripation Boom o,,....�. �_ � �.
/'�% �^ d —
eh rein on die daf�tated ��
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months from validafion date printed in this box.
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Requesi Dafe Rough-in inspection required2 Yes ❑ No Inspection Other Than RougMn: ❑ Ready Now ill Call
�+ � --� � (You must call fhe inspector when ready) Date Reody:
1, �icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or. oute No.) City Zip Code
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�'on No. Township Name or No. Ranae No. ' Fire No_ .n�mw
Occupant
Power
dress (Conhacfor or Owner Performing
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Signature (Cyiyoclw w Owner Pe�fn msmuanon) � r O/� � I p
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BOAR[1 COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
Phone No.
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Address
Confracror License No. Master
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