P - 838104��:34�
REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
>i Home Duplex Apt. Bldg. Uther:
Commercial Industrial Farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the
New
Remod
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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
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Am
Transformer/Generator INSPECTOR's use oN�v TOTA
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
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Fee
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Investigative Fee � Z-3
THIS INSTALLATION MAY BE ORDERED DISCO TED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date prinfed in this box.
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Requesf D Rough-in inspecfion required? � pe g- ❑ Ready Now ��II Call
9te_ �� ,_� ❑ No Ins ction Other Than Rou h In:
L� �� (You must call the inspector when ready) Date Ready:
I, [�]'ficensed contractor ❑ owner hereby �equest inspection of the above electrical work at:
Job Address (Sireet, Box, or Route No.) City Zip Code
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Section No. Township Name No. Ranqe No. fire No. Cou �
Occupanf
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Power Supplier
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Electrical Confracfor (Company Name)
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Mailing Address (Contracror or Owner
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Authorized SiAnature �Confractor or O�
Conhactor License N
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Performing Installation)
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vner Perfor g Installafion)
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Phone No.
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