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Air Conditioner Htg. Equip.
Dryer Range
"X" above the work covered by �
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REQIfEST 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
Other: New Addn
Form
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
is request. Enter remarks in ihis space and on
Calculate Inspection Fee - This Inspecfion Request will not be
Other Installations Pee # Service Entrance Size Fee
Mobile Home Park Stall 0 to 200 Amps
Street Ltg. / Traffic Sig. Above 200 Amps
Transformer/Generator INSPECTOR'S USE ONLY
$ign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the elechical i
Irriaation BoEhi r�. � o..,,,.� �..
copy
� without the correct fee:
Circuih / Feeders Fee
0 to 100 Amps
Above 100 Amps
TOT9y.�[
Investi2ative Fee F���� � s ��------��— I�����d� d� I
THIS INSTALLATION MAY BE ORDERED D1SC0 CTED IF NOT COMPLETED WITFiIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months hom validation date printed in this box.
i������{I�NI�NI����IN��NhI�I� • °�° ��
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PLEASE PRINT OR TYPE
Reque ate Rough-in inspecfion required? ❑ Yes No Inspecfion Ofher Than Ro h-In: ❑ Ready Now � Will Call
� You must call fhe inspecfor when ready Date Ready: 1 ' —
l, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Ad ss eet, Box, Route No.) � �� City Zi� e���
J
i n o. ownship Name o! No. Ranqe No. Fire No. Cou . �
I Power
Phone N
�
Addr s
P�s 1���1
Conh cbr License No.
or Owner erforming In allafop�, I
�. � � ��1 �'1�\r��i� �l ��,
m�any_or Vwner� rtori
7 � � ,
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STATE BOARD COPY
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY