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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
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Commercial Industrial Farm Remod Re ai
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 back the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted wiihout the correc► fee: �(�. (.�i�
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps it� 0 to 100 Amps .�
Street Ltg./Traffic Sig. Above 200 Amps .,Z ,(T Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL _�_
Sign/Outline Ltg. Xfmr. �+E}�
Alarm/Remote Control /7����j
Swimming Pool �
I hereb certi that I ins ted the eledrical installation described herein on fhe dafes stafed
Irrigation Boom Rough-In ��� Dafe
Special Insp "" t' � ` lQ—
. Final ' D e �
Investigative ee -
_THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
- OFFICE USE ONLY This requesf void 1 S months from validation date printed in this box.
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* � 5 1 9 � 7 4 9�k PLEASE PRINT OR TYPE 7'� ��
Request Date Rou h-in ins tion re uired?
3� 9 P� q ❑ Yes No Inspecfion Ofher Than Rough-In: ❑ Ready Now Will Call
' �You must call the inspecfor when ready) Dafe Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or Route No.� Ci Zip Code
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Section No. Township Name or . • Range No. Fire No. Counfy _ �
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Power $upplier
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Electrical Conhactor �Company Name�
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EB-0OOOlA-1� 8/96 STATE BOARD
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Confracipr License
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Phone No.
N,b � �3►-vo�ly►� '(�-�.
� Master Lic. No. (?lant Elect. Orly�