P - 82610REQUEST FOR ELECTRICAL �NSPECTION
(� d Q � � � � � Q � Minnesota State Board of Electricity � �' �
�•'�' �� � 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 � `�
(651) 642-0800 www.electricity.state.mn.us �'.�4- `�
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial farm Remod Repair
� Air C " ner Htg. Equip. Wafer Hfc Load MgmL Other:
Dryer Range Elec. Heat Temp. $ervice
"X" above the work covered by this requesi. Enter remarks in this space and on the back of the white copy only.
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Calcvlate Inspection Fee - This Inspection Request will noi be accepted without fhe correci fee:
Other Installafions Fee # Service Enfrance 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. � � i� ,
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ecfed the electrical installafion described herein on the dates stated:
Iffl9afl0� BOO _ Rough-In ' Dafe
Special Inspe
Investigative Fee Final p°te �,,�,� c v
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validafion dafe prinfed in this box.
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PLEASE PRINT OR TYPE
Req�uesit Date Rough-in inspection required? ❑ Yes
rt � _� ^ ❑ No Inspecfion Other Than Rough-In: �eady Now ❑ Will Call
/ �� You musf call fhe inspecfor when ready Date Ready:
I, �.licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: