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REGIUEST FOR ELECTRfCAL INSPECTION
Minnesota State Board af Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 5510A
Phone (612) 642-0800
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Commerc+al Industrial Farm Remod Re al
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above th work covered by this request. Enter remarks in this space and on ihe back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will no� be accepied wiihout ihe correct fee:
Other Fee #, rvice Entrance Size Fee # CircuitsJFeeders Fee
Mobile Home Park Stall to 200 Amps 0 to 100 Amps
Street ltg./Traffic Si . Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT
Sign/Oudine Ltg. X�rnr. �
Alarm/Remote Control
Swimming Pooi
I hereb certi thaf I ins the eleckical insfallation deuribed herein on Ihe dates stated
Irri9ation Boom RougMn .. ... Daie
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. Final Date � �,/ �y �
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from va�idafion date prinfed in this box.
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PLEASE PR1NT OR TYPE
Requesf Rough-in inspecfion required? ❑ Yes o Inspection Other Than Rough-In: ❑ Ready No ill Call
'"fJ) (You musi call fhe inzpector when ready) Date Ready: �
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I, �licensed conhactor ❑ owner hereby request inspection of the above electrical work at:
Job Addreu (Street, Box, or RouM No.) City Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Couny
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Conhacfor �Company Name�
Mailing Address �Conhactor or
or
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Insrollafion)
STATE BOARD COPY - SEE
Phone No.
Conhacfor License No.
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ON BACK OF YELLOW COPY
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