P - 82054C���17-�97 �
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REQUEST FOR ELECTRICAL INSPECTION ��
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Minnesota State Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -
(651) 642-0800 www.electricity.state.mn.us n���
Home Duplex Apt. Bldg. Other:
Commercial Industrial Farm
Air Conditioner Hfg. Equip. Water Htc Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service _
"X" above the work covered by this request. Enter remarks in this space
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Calculaie Inspection Fee - This Inspecfion Recjuesi will not be a
Otherinsfallations Fee # Service Enhance Size Fee
Mobile Home Park Stall 0 to 200 Amps pp °°
Street Ltg. / Traffic Sig. Above 200 Amps
Transformer/Generator INSPECTOR'S USE ONLY
Sign / Outline Ltg. Xfmr. -
Alarm/Remote Control
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on
copy
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without the correct fee:
0 to 100 Amps L
Above 100 Amp:
TOTAL
Repair
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unyunun qyVn� ' Rou�h-In � Dafe
Special Inspecfion W d —� '{"�
Investigative Fee F�� , 2`�— � 2�
THIS INSTALLATION MAY BE ORDERED DISCO ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request vad 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Date Rough-in inspecfion required? ❑ Yes �10 Inspecfion Ofher Than Rough-In: ❑ Ready Now �'ill Call
(,� �s�A4 You must call the inspecror when ready Date Ready:
I,�icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
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