P - 82435REQUEST FOR ELECTRICAL INSPECTION
��� C� ���� o � Minnesota State Board of Electricity
J �� 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us
ome •Duplex Apt. Bldg. Other: New
Commercial Ind trial Farm emod
Air Conditioner fg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work overed by this request. Enter remarks in this space and on the back of the white copy
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Calculate Inspection Fee - This Inspection Request will not be accepted without ►he correct fee:
Other Installations Fee # Service Enhance Size Fee # Circuih / 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
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$ign / Outline Ltg. Xfmr. ,
Alarm/Remote Control
Swimming Pool
I herebvi certiH that I insoected the electrical installation described herein on fhe dates stafed:
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Repair
Special Insp�L'I�ioN V �-'
Fina� �
Investigative Fee �i"
THIS INSTALLATION MAY BE ORDERED DISC CTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This request void 1 m nf Il�don date prinfed in this box.
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PLEASE PRINT OR TYPE
Request Dat Rough-in inspection required? ❑ Yes o Inspection Other Than RougMn: ❑ Ready Now ill Call
You must call ihe inspecror when ready.� � Dafe Ready:
I, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Street, Box, or Rou No.) Ciy Zip Code �
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Secfion No. Township Na e or No. Range No. Fire No. Co
Q��� �. �i � ca.cCiT.
ontra � � M.E.
ANOI�A. MN 55304
Idr ss (Contractor, ompa r n �r�g
ignature onf � o� Company orQwner Perfori
"12 ��� STATE BOARD COPY
Phone No.
Contractor License No.
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SEE INSTRUCTIONS ON BACK OF YELLOW