P - 80289E
� REQUEST FOR ELECTRICAL INSPECTION
' V-853-000 �8 Minnesota State Board of Electricity -
1821 University Avenue Suite 5-128, 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.
Ca/culate Inspectii
Other Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
TransformeNGenerator
Sign 1 Outiine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
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NSP SAVER'S SWiTGH 1(VSTALLRTION
Fee - This Inspection Request will not be accepted without the correct fee.
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0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL
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I hereby certify that I inspected the electrical installation desctibed herein on the dates stated:
Rough In Date
� Investigative Fee � �- I��,�—¢1 I
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This request void 18 rtwnths from va�idation date printed in this box.
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Q 7� JCiB�MBER #!99[�3000
*0853000$*
` PLEASE PRINT OR TYPE
Request Date Raugh-In inspection required?�] Yes � No Inspection Other Than Rough-In: Ready Now � Will Call
.��',�� You must call the inspector when ready! Date Ready: ��'rf�
I, � licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: