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Home � Dupiex
Commercial Industrial
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REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �r
Phone (612) 642-0800 `'�'
Apt. Bldg. Other: New Addn
Farm Remod Re ir
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enier remarks in this space and on the back of the white copy only.
Calculate 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 TOTALSp
Sign/Outline Ltg. Xfmr. ���
Alarm/Remote Control
Swimming Poo{
I hereb certi thal I ins ted the elechical installation described herein on Ihe dotes stated -
Irrigation Boom � RougMn Dare
Special Inspec
Finol re
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED NOT COMPLETED WITHI 18 M HS.
OFFICE USE ONLY This request void 1 from validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Requesf DaM Rough-in inspeclion required? pec' g- dy ❑ Will Call
❑ Yes No Ins hon Other Than Rou h In: � Rea Now
��'�.�� �You must call fhe inspecfor when ready� Date Ready: � �
I, � licensed conhacror ❑ owner hereby request inspection oF the above electricol work at:
)ob Address �Sfreef, Box, or Route No.) City Zip Code
G oG�- l.rJoor�/ ca,�e F-,clle
Secfion No. Township Name or No. Ranpe No. Fire No. CavnN
OccupaM
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Power Supplier �
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Elechical Contracror �Company Name)
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Mailing Add�ess (Controctor or Owner Per4a
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Authorized Signature (Confractor or Owner f
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Phone No.
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Lic.
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- SEE INSTRUCiIONS ON BACK OF YELLOW COPY *�