P - 82123��.��41-992 �
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 =`
(651) 642-0800 www.electricity.state.mn.us ''�'
Home Duplex Apt. Bldg. Other. N�• �
ommercial Industrial Farm
Air Condifioner Hfg. Equip. Wafer Htr. Load Mgmi. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in ihis space
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on
copy
Calculate Inspection fee s inspection Request wil� not be accepted without ihe correct fee:
Other Instollations Fee # Service Entrance Size Fee # Circuits / Feeders_ Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Lig. / Troffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA
Sign / Outline Ltg. Xfmr. '
Alarm/Remote Control � �
Swimming Pool
Repair
1 hereb certi that I ins ted ihe eleckical insfallation described herein on the dates srofed:
Irri9ation Boom Roughan Dafe
Special Ins
Final Da
Investigative e —
THIS INSTALLATION MAY BE ORDERED DISCONNECTED iF NOT COMPLETED WiTHIN 18 MONTriS.
�— OFFICE USE ONLY This request void 18 months from validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Reques� D Rough-in inspecfion required8 ❑ Yes ❑ No Inspecfion Ofher Than Rough-In: Ready Now ❑ Will Call
�� ' Q� You must call fhe inspector when ready Date Ready:
I, ficensed contractor ❑ company ❑ owner hereby request inspection oF the above electrical work at:
Job Ad ress (St�, Box, or u No') �/ Ciry Zip Code
I
Secfion No. Township Name or No. Range No. Fire No. Coun /
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� I Address
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$ignafure (Contr , mpany or
Phone No.
Conkacfor license No.
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Phone Number
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY