P - 82218'� REQUEST FOR ELECTRICAL INSPECTION
8� b-19 7� Minnesota State Board of Electricity �
, 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612) 642-0800 "�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesi. Enter remarks in this space and on the back of the white copy only.
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Calculaie 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
Transformer/Generator INSPECTOR'S USE ONLY TOT
Sign/Outline Ltg. Xfmr. �d� �
Alarm/Remote Control
Irrigation Boom RougMn Date
Special Inspecti
Investigative Fee Final Datep_ Q`��
�S
THIS INSTALLATION MAY BE ORUERED DI��ONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
,_.. OFFICE USE ONIY This requesf void 18 months from validation date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection required$ ❑ Yes o Inspection Other Than Rough-In: eady Now ❑ Will Call
� �(� (You must call the inspecfor when ready� Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Roufe No.� Ciy _ . Zip Code
Section No. � Township Name or No. � Range No. � Fire No.
Occupant
Power Supplier � " Address
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or
Phone No.
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No. Master Lic. No. (Plant EIf
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Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY