P - 80321U���99-088 �
Apt.
REQUEST FOR ELECTRICAL INSPECTION ��
Minnesota State Board of Electricity �
1821 UniversiTy Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 �i
(651) 642-0800 www.electricity.state.mn.us
Air Conditioner Htg. Equip. Water Htr. Lood Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy
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Calculate Inspection - This nspection Reques► will not be a ce ted wiihout the correct fee:
Other Instollations Fee # Service Entrance Size Fee # Circuits / feeders Fee
Mobile Home Park Slall to 200 Amps 0 to T00 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAI,_,�
Sign / Outline Ltg. XFmr. ��
Alarm/Remote Control
Addn
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I hereb ceAi fhat I ins ted the electrical installation described herein on the dates stated:
Irriyation BiS Rough-In Da�e _ i7,_�
Speciaf In c o �
Final Dat
Investigative Fee - �� � ��
THIS INSTALLATION MAY Bf ORDERED DISCO ED IF NOT COMPLETED WITNIN 18 MONTHS.
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OFFICE USE ONLY This requesf void 18 months from valid n d inf� ii this box.
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PLEASE PRINT OR TYPE
Request Date � Rough-in inspection required2 Yes ❑ No Inspection Ofher Than Rough-In: ❑ Ready Now�Nill Call
�...� ��,� b� You musf call the inspecfor when rea Dafe Ready: '\
1, �licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: