P - 82146U�8192-�23 C�
REQUEST FOR ELECTRICAL INSPECTION ���
Minnesota State Board of Electriciry
1821 University Avenue Suite 5-128, 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. Water Htr. load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Cakulate Inspection Fee - This lnspection Requesi wi!! not be accepted without the correct fee:
OTher Installations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall to Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generafor WSPECTOR'S USE O�tE� - TOTAL
Siqn / Outline Lts�i Xfmr. '�
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I hereb ceAi thaf I ins cted the electrical installation described herein on the dates staied:
Rough-In . Dafe
Special Inspe
Final . Da 5 ^ ��
Investigative Fee `�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF N� COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesivoid IS mo�}hs from validafion dafe prinfed in fhis box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required$ ❑ Yes ❑ No Inspecfion Ofher Than Rough-In: Ready Now ❑ Will Call
5� �� Q 4 You must call fhe inspector when reody Date Ready:
I, �icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Addres�(S�t,�� uie ;.) - Ciy��•.� `�, / Zip Code
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Supplier
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�s �Coniracbr, Company or Owner Performing
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naiu� �Confmcror, Company or Owner Perfori
5�1999 S7ATE BOARD COPY
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Phone No.
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SEE INSTRUCTIONS ON BACK OF VELLnw Cnov