P - 82617U��76-97� �
Home Duplex
REQUEST FOR ELECTRICAL INSPECTION �������
Minnesota State Board of Electricity �
1621 Universiiy Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 =°
(651) 642-0800 www.electricity.state.mn.us "�'
Other: New Addn
Commercial Indusfrial - Farm rcemoa rtepau
Air Co ' ner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by this request. Enter remarks in �his space and on fhe back of the whiie copy only.
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Calculate Inspecfion Fee - This Inspeciion Request will not be accepted without the correct fee:
Other Insfallafions 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 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr. !�
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the electrical installation de:cribed herein on the dates stafed:
Irrigation Boo Rough-In Dare
Special Inspec
Final � ��� /
Investigative Fee �
THIS INSTALLATION MAY BE ORDERED DISCO ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 1 8 months from valiclation date printed in fhis box�
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*09769761* ��335
PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection required? ❑ Yes ❑ No Inspecfion Other Than Rough-In: eady Now ❑ Will Call
.� ���� You musf call fhe inspecror when ready Date Ready:
I, �licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: