P - 82183U-�"55-523 �
REQUEST FOR ELECTRICAL INSPECTION �
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Minnesota State Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us '��'�
Other: New Addn
Commercial Indusfrial Farm
Air Co i i 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 this space and on the back
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copy
Calculate Inspection Fee - This Inspection Request will not be accepted wifhout the correct fee:
Ofher Installafions Fee # Service Enfrance Size Fee # Circuiis / 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 TOT L
Sign / Oudine Ltg. Xfmr. /�
Alarm/Remote Control �
Swimming Pool
I hereb certi that I ins ted the eleclrical installation described herein on the dares stated:
Ir�igation Boo , i Rouoh-In Dare
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Imestigative Fee
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THlS INSTQLLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validafion dafe prinfed in this box,
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? ❑ Yes ❑ No Inspection Ofher Than Rough-In: Ready Now ❑ Will Call
— �'�� You must call the inspector when ready Date Ready:
1, �4icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: