P - 82215J-955-�37 �l
Htg. Equip. � � Water Htr
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity �� 3
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -'
(651) 642-0800 www.electricity.state.mn.us '�'
Mgmt
Repair
Dryer I I Range I I Elec. Heat I I Temp. Service I
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
���ac�n��� 1�C:_ � ��x.r�1 aG�
Calculate Inspection Fee - This Inspection Requesi will not be accepted without the correct fee:
Oiher Insfallations Fee # Service Enirance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA� , _
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irripation Boom
c7d�/
I hereb certi fhat I ins ted the elechical installotion described herein on the dates stated:
Rough-In Dafe
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Investigative � ,:__..,__ �-2-�'% ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe —�� Rou h-in ins ection re uired6 ❑ Yes
g p q ❑ No Inspection Other Than Rough-In: Ready Now 0 Will Call
You musf call fhe inspector when ready Dafe Ready:
I,�jicensed contractor ❑ company ❑ owner hereby request inspection of the above elechical work at: