P - 80337REQUEST FOR ELECTRICAL INSPECTION
r, _�� ry-��� � Minnesota State Board of Electricity �� a
� U L 1821 University Avenue Suite 5-128, 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. Wafer 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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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Installations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stal) 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 Y��–�
Sign / Outline Ltg. Xfmr. ���
Alarm/Remote Control
$wimming Pool
I herebvi certiH that I insoected the elechical installafion described herein on the dafes stafed:
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Investigative Fee
THIS INSTALLATION MAY BE ORDERED DIS NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monlhs from validafion dafe prinfed in fhis box.
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PLEASE PRINT OR TYPE
Request Date Rou h-in ins ection re uired? ❑ Yes
g p q ❑ No �nspection Other Than Rough-In: eody Now ❑ Will Call
�� Q � You must call the inspecfor when ready Date Ready: �
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
1ob Address �Street, Box, or Roufe No.) City Zip Code
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I Power
or No. I Range No. � Fire No.
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Phone No.
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Name '� �. V�/ l�[ I Confracfor License No. I Masfer Lic. No.
or Owner
(Confractor, Company or Owner Performing Installafiofi) Phone Number
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� STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY