P - 82402�-.�03-337 �
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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -
(651) 642-0800 www.electricity.state.mn.us '�'
Other. New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Wafer Htr. Load Mgmt. Other.
Dryer Range Elec. Heat 7emp. Service
"X" above the work covered by ihis 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:
Other Insfallations Fee # Service Enirance Size Fee # Circuits / Feeders fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Lfg. / Traffic $ig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL�
Sign / Outline Ltg. Xfmr. � �
Aiarm/Remote Control
Swimming Pool
I hereb certi ihat I ins ted the electrical installation described herein on the dates stated:
Irrigation Boo Ro�Mn Dar�
Special Inspe
Final Dpte � .L�
Investigative fee ,7
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 mon s from validafion �,dfe prinfed in fhis box.
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* 1 0 0 3 3 3 7 1 * ���'�
PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required$ ❑ Yes ❑ No Inspecfion Other Than Rough-In: eady Now ❑ Will Call
� l/�b6 You must call the iospecfor when ready Date Ready:
I, ❑ licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: