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REG�UEST FOR ELECTRICAL INSPECTION �' °E
Minnesota State Board of Electricity _
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -
(651) 642-0800 www.electricity.state.mn.us
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. �; Load Mgmt. Other.
Dryer Range Elect. Heat Temp. Service
X" above the work covered by this request. Enter remarks in this space and on the back of the white copy on/y.
Calculate Inspecti
�ther Installations
Mobile Home Park Stall
Street Lta. / Traffic Sia.
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Fee - This Insnection Reauest will not be accevted without the correct fee.
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Am�
INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr. I
Alarm/Remote Control —1
Swimming Pool
i
Irrigation Boom p
Speciallnspection 2p.9Li
Investigative Fee �
THIS INSTALLATION MAY BE
�II III�I ��II� II�II �I
* 1 0 1 6 7 4
1 inspected the electrical installation described herein on the
Date
—��/� �_ I �`+�--� 31 _ d/ I:
SCONNECTE ...............:.....................................�N 18 M(�NTH�:-
USE ONLY This request vad 18 montha fran validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-In inspection required? ❑ Yes ❑ Inspectian Other Than Rough4h: � Ready Now ❑ Will Call
���_�%���� You must call the inspector when ready! Date Ready: ()E'jf�Q�(]�]
I, �licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: