P - 81203T
REQUEST FOR ELECTRICAL INSPECTION �`�°
� 0-854'6GO � 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 Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range E�ect. Heat Temp. Service
X" above the worrc covered by thls request. Enter remarks in this space and on the back of the white copy onry.
NSP SAVER'S SIMTCH INSTRLLATIQN
Calculate Inspecti
�ther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline,�g,�jCfjpr
� Pool
Boom
Fee - This Inspection Repuest will not be accepted without the correct fee.
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL .�
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I herebvi certifv that I insoected the electrical installation described herein on the daU
oate
Irnestigative Fee F��� � y��.� ---- I D��-��^�C� I
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This request vad 78 months from validation date printed in this box.
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Request Date Rough-In inspection required? � Yes ❑�° Inspection Other Than Rougluln: � Ready Now ❑ Will Call
You must call the inspector when ready7 ' Date Ready: �
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I, [J19icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: