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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity 3
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 -
(651) 642-0800 www.electricity.state.mn.us "�'
�iome Duplex Apt. Bldg. Other: New Adc
Commercial Industrial Farm Remod Rep
Air Condifioner Htg. Equip. Water Htr. Load Mgmt. Other.
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. En�er remarks in this space and on the back of the white copy only.
SERVICE CHANGE OUT,ADD LAUNDRY CIRCUIT� MISC.
Calculate
Mobile Home Park Stall
Street Ltg. / TrafFic Sig.
Tra nsFormer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimmin Pool
Fee - This Inspec►ion Request will not be accepied withoui ihe correct fee:
# Service Entronce Size Fee # Circuits / Feeders Fee
� 0 to 20Q Amps 3 Q to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL
�. �4 2 . 5 0 °
9 I hereb ceAi fhat I ins ected ihe electric ' stallption described herein on the dofes-stated:
Ir�igation Boom Rough-In • � O�
�°i--�_ �4f�'
Special Inspec � � Final — Date �
Investigative Fee '— �
THIS fNSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. _�,_
--- — --- --- -_ _ _
OFFICE USE ONLY This requesl void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection required$ ❑ Yes �lo Inspection Ofher Than RougMn: ❑ Ready Now ill Call
9- 2 5- 0 0 You must call the inspector when ready Date Ready:
I, 0 licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: