P - 8331770�-507 Q
RE(�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
i821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612) 642-0800
/ Home Duplex Apt. Bldg. Other:
Commercial Industrial Farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" abo fhe work covered by this requesi. Enter remarks in this space ond on ihe
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of the white copy only.
Calculate 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
Street Ltg./TraFfic Sig. Above 200 Am s Above 100 Amps
Tronsformer�Generator INSPECTOq�S USE ONLY TOT
Sign/Outline ltg. Xfmr. �C/f/-
Alarm/Remote Controi
Swimming Pool
I hereb certi that I ins ted the elechical instolloNon dexribed herein on the dates stated
Irrigation Boom RougMn Dare
Special Inspecti
Investigative Fee ' � �� = .-�--Oo
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This requesf void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requ f Dafe � � Rough-in inspection required$ ❑ Yes No Inspection Other Than RougMn: eady Now ❑ Wili Call
� �You must call the inspector when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Power
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or No. — � Range No. � Fire No.
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or uwner re rming Ins alion� � �
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f�for or Ow Performing Insfal afion) �� Pho /
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY