P - 82581REQUEST FOR ELECTRICAL INSPECTION �`�-E
�"'014-828 ❑6 Minnesota State Board of Electricity �_ `�o `�
, 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 ��
• (651) 642-0800 www.electricity.sfate.mn.us �:���
v Home Duplex Apt. Bldg. Other: New Atltln
Commercial Industrial Farm Remod Repair
Air Contlitioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elect. 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.
NSP SAVER'� �WITGN � � �g ,Q �
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Calculate Inspection Fee - This lnspection Request will not be accepted without the correct fee.
Other Installations Fee # Service Entrance Size Fee # Circuits / 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 TOTAL
Sign / Outline Ltg. Xfmr. ''t'a,�jQ
Alarm/Remote Control
Swimming Pool
I hereby certiiy that I inspected the electrical installation described herein on the dates stated:
Irrigation BOOfTI Rough In Date
Special Inspection
Investigative Fee F"'a� — � �Q_s�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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I IIIII� IIIII IIIII IIII� IIIII IIII III IIII IIII OFfICE USE ONLY This request void 18 months from validation date printed in this box.
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* 1 0 1 4 8 6* ��-�, .� � 1'�o��
PLEASE PRINT OR TYPE
Request Date
Rough-In inspection required? ❑ Yes � Nd� Inspection Other Than Rough-In: � Ready Now ❑ Will Call
You must call the inspector when ready! Date Ready:
I, [j,jicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
"'-""""'^-'° ""�y STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YE�LOW COPY