P - 82553REQUEST FOR ELECTRICAL INSPECTION
U� 9 3 7. �� 7 5 � Minnesota State Board of Electricity ���
1821 University Avenue Suite S-128, Saint Paul, Minneso[a 55104-2993
(651) 642-0800 www.electricity.state.mn.us ;��"�
;, .
Calculafe Inspe
Other Installations
Mobile Home Park $tall
Street Ltg. / Traffic Sig.
Tra n sformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irriqation Boom
Fee
request. Enter remarks in this space and on the back of the white copy only.
c���, ���y � ��-�
Fee - This Inspection Requesi will not be accepted without the� r(�c�fe� ���
# Service Entrance Size Fee # Circuits / Feeders Fee
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL
I �-� L l�
o� r�
I hereb certi thaf I ins ected the electrical installation described herein on the dates stated:
Rough-In Dafe
�'�` �Z d/
Investigative Fee � - j �
THIS INSTALLATION MAY BE ORDERED DISCO ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinfed in this box.
I ll�� �� II� �I �i� �� ��� �� �II �� �i� �I�I���� �� l�� � lll� Q �i �, �,�..�
* 0 9 3 7 8 7 5 3* ����L� I�'u���S ���: ��"
PLEASE PRINT OR TYPE
Requ st Dafe Rough-in inspecfion required? ❑ Yes �o Inspecfion Ofher Than Rough-In: ❑ Ready Now�Will Call
�'� q��� You musf call the inspector when ready Date Ready: ���
1, �censed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: