P - 81648i i R i � �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 =
(651) 642-0800 www.electricity.state.mn.us "�'
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Calculate Inspeciion Fee - This Inspection Requesf will not be accepted withoui the correct fee:
Other Installations Fee # Service Enhance 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. n/�'L2� fs '��
Alarm/Remote Control ���� C�
Swimming Pool I�
I hereb certi that I ins ted the elechical installation described herein on the dotes stated:
Irrigation Boom Rough-In Dare
Special Inspection 2
Investigative Fee Finol D �— �!
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� OFFICE USE ONLV This request void 18 monfhs from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection required$ es ❑ No InspeMion Olher Than Rough-In: Ready N all
— / You musf call the inspecfor when ready Date Ready:
I, �4censed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
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Job'Address �Streef, Box, or Route No.� , _ Cify Zip Code
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