P - 80780� REQUEST FOR ELECTRICAL INSPECTION E
,,/ 0-8�4_�Q4 a Minnesota State Board of Electricity
V 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us : - �`�
Home Duplex Apt. Bltlg. Other: New Adtln
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 only.
PiSP SRVER'S SIMTCH INSTALtA7lON
Ca/cu/ate Inspecti�
�ther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimmina Pool
Fee - This Inspection Request will not be accepted without the correct fee.
�e # Service Entrance Size Fee # Circuits / Feeders I
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL �j
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I hereb certi that I inspected the electrical installation described herein on the dates
Rough In Date
�'� � Investigative Fee �'� �'� �' ��� �I �j-'�j��--dJ I
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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"� OFFICE USE ONLY This request void 18 rnonths from validation date printed in ihis box.
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*08545840* `3
Request Date `�`�� � �'^�~�� T�O�'�^'
Rough-In inspection required? ❑ Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now ❑ Will Call
You must call the inspector when ready� Date Ready: x
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I, Q_licensed contractor ❑ company ❑ owner hereby request inspection of the above electricai work at:
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