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Home Duplex
Commercial Industri
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Calculate Inspection Fee - This Inspe
Other Fee
Mo,bile Home Park Stall
Sheet Ltg./Traffic Sig.
Transformer/Generator
Sign/Outline Ug. Xfmr.
Alarm/Remote Control
Swimming Pool
Irrigation Boom _.
REf�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0809 _ .n
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Farm �
Water Htr. load Mgmt. Other:
Elec. Heat Temp. Service
New
Remod
request. Enter remarks in this space and on the back of the white copy
m Request will not be accepted wifhout fhe correct fee:
# Service Entranc Size Fee # Circuits/Feed�
�. 0 to 100 Amps
Above 200 Am s Above 100
INSPECTOR'S USE ONLY TC
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN i8 MONTHS.
.. OFRCE USE ONLY Tl�is request void 1 B months from validation date prinfed in this box.
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IN IIIIIIIIHII�IIillllllllllllll�� ,�
* 0 5 3 2 5 0 9?* a� �
PLEASE PRINT OR TYPE
R�1�� � Rough-in inspection required2 Yes ❑ No InspecKon Other Than RougMn: 0 Ready Now �II Coll
Q� 2 g/y 8 (`/ou must call ihe inspector when ready) Date Ready:
I, ❑ licensed contracror f$� owner hereby request inspection of the above elecFrical work at:
Job Address �Street, Box, or Route No.) Ciy Zip Code
50,6 R►cE ���E►�T �QAeE FR ���c-y 5543�
Section No. Township Nameo,� Range� .� Fire No. County
�'1 AN6 A
Occupant e No.
L�oyD N� ETt,� Nf� �612) 5?4-7'3go
Power Supplier �� Address � �
C
Electrical Conhactor J�ompany Name) C hncror License No. Master Lic No. IPlnnt Eleet. Onlvl
Performing In
or Vwner erlor ing ns'NYb11J) � C� � Phone No.
,�1 � �4 - � �40
STATE BOARD OPY - SEE INSTRU S ON BACK OF YELLOW COPY