P - 82120��� �Q��79 �
REQUEST FOR ELECTRICAL INSPECTION �T"E�
Minnesota State Board of Electricity �VLS 3�
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 (,�� n,,,E �r �� �t r-t� Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in fhis space and on ihe back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Ofher Installations Fee # Servic Entrance Size Fee # Circuits / Feeders fee
Mobile Home Park Stall 0 to 00 Amps ' 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TO ,[ c�
Sign / Outline Ltg. Xfmr. Ji cJG/
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins ted he electrical installation described herein on the dates stated:
Irrigation Boo Rough-In Date �7
Speciallnspe n � '� � ���` �
Final
Investigative fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Dale Rou h-in ins fion re uired8 �'es
g pec q �❑ No Inspection Other Than Roughdn: ❑ Ready Now �Will Call
�� 3� D� You musf �call fhe inspecfor when ready � Dafe Ready: � �
I, �licensed contractor ❑ company ❑ owner hereby request inspection of the above electricai work at: