P - 82099(���0�-Q76 �
ome Duplex Apt. Bldg.
Commercial Industrial Farm
Air Conditioner Htg. Equip. Water Htr
Dryer Range Elec. Heat
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity �'
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 =
(651) 642-0800 www.electricity.state.mn.us "�'
Repair
�" above the work covered by ihis equ st. Eni r marks in this space and on ihe bock of the white copy only.
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Calculate Inspection Fee - This Inspeciion Request will nof be accepted withoui ihe correci fee:
Ofher Installations Fee
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Tra nsformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irriaation Boom _
# :
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY T �' �
electrical
on rne aa
Date
� � Investigptive Fee � � � � r �E� "'U"
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED _WITHI_ 18 MONTHS�
_��— OFFICE USE ONLY This requestvoid 18 monihs from validation date printed in this box.
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PLEASE PRINT OR TYPE
Reque�� � Rough-in inspecfion required? ❑ Yes o Inspecfion Other Than Rouglrin: Ready Now � Will Call
� You musf call fhe inspector when ready Dafe Ready:
I, 'censed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Skeet, Box or Route No.� Ciy Zip Code
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Secfion No Township Name or No. Range No. Fire No. County �
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Occup
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Power Supplier Addre:
EI al Contractor omp ny Name �
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Mailing Addreu (Confracfor, Com ny or Owner Pe rming Instalb
/ 65'!� 5 �uo� Q�
Authori�.C) Sianafuu IConhacfor. Com or Owner Performin r
Phone Na
Lic. No.
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STATE BOARD COPV SEE INSTRUCTIONS ON BACK OF YELLOW COPv