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REG�UEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 ��
Phone (&12) 642-0800
Other. 1�i � �� ew Addn
Commercial Industrial Farm (f d1�J Remod Re
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspecfion Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size e Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
treet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generaror INSPECTOR'S USE ONLV TOTAL __
Sign/Outline Ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool
Irriqation Boom _
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I herebvi certifv that I insoected the electrical installation deuribed herein on ihe dates slated
� Final I Date.�
Investigative Fee ,
THIS IMSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18
Power
OFFlCE USE ONIY This request void 18 monfhs from validation date prinfed in this box.
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PLEASE PRINT OR TYPE
Rough�in inspecfion required$ ❑ Yes o Inspecfion Other Than Rou -In: Ready N �II Call
y(`(ou musf call the inspecfor when ready) Dafe Ready: /l
contractor ❑ owner hereby request inspection of the above elechical work at:
Box, a Roure No.� � Ciry � Zip Code
or
�(/ A
Address (Conhactor or Owner Performing
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Range No. fire No. County
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Phone No.
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Conhactor License No. � Master Lic. No. (%aM Elecf. Only�
or uwner rerrorming insrananon) � � � ri
�.�- �65� �
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY