P - 82173REQUEST FOR ELECTRICAL INSPECTION ��
��� J� O-17 3� Minnesota State Board of Electricity
. 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 ��:
(651) 642-0800 www.electricity.state.mn.us " '
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusirial Farm Remod Repair
Air Co er Htg. Equip. Water Htr. Load Mgmi. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in Ihis space and on the back of the while copy only.
R�.�o r��ne�� � °� �ur�a�
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Installations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park $tall 0 to 200 Amps 0 to 100 Am s
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTPIL
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool �
installation described herein on the dates stated:
Dare
Investigative Fee F'�a� ( � -` ____.1-"� /6�� I
,
THIS INSTALLATION MAY BE ORDERED DISCO TED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
1�����1������������������� � ao.�
�09501735* 3a��
PLEASE PRINT OR TYPE
Request Date �O Rough-in inspection required? ❑ Yes ❑ No �nspection Other Than Rough-In: eady Now ❑ Will Call
You must call the inspecfor when ready Date Ready:
1, �icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: