P - 79808U-90�-889 �
Home Duplex
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity 3
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ���.
(651) 642-0800 www.electricity.state.mn.us " '
Other. L I/ / �1 . New Addn
Commercial Indusirial Farm Kemotl Kepair
Air Conditioner Hfg. Equip. Water Htr. Load 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 only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Ofher Instollafions Fee # Service Enhance Size ee # Circuits / Feeders Fee
Mobile Home Park Stafl j 0 to 200 Amps � 3� 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL r,
Sign / Outline Ltg. Xfmr.
Alarm/Remote Contr
Swimming Poo) I hereb ceni thal I ins ted the electrical installation described herein on the dates smted:
Irri9ation Boom Rough-In �a�
Special Inspection
final Dare
Investigative Fee '�- G'%
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validaiion date printed in fhis box.
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PLEASE PRINT OR TYPE
Req Date _ __ � Rough-in inspecfion required$ ❑ Yes �No Inspecfion Other Than Rough-In: ❑ Ready Now �'Will Call
��'�1j � You must call �he inspector when ready Dafe Ready:
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I,�ilicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: