P - 80335,
-Um892-559 �
Home
REQUEST FOR ELECTRICAL INSPECTION �'�
Minnesota State Board of Electricity .[ �'
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -
(651) 642-0800 www.electricity.state.mn.us '�
Apt. Bldg. Other: New Addn
Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Uther:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on 1he back of the white
`��:�-� �t,�. � �� � � i � c� -
�zd � -�� U�� I � C.��r�� �
Calculate Inspection Fee - This Inspection Request will not be accepted wi►hout the correct fee
Other Instafiations Fee # Service Entrance Size Fee # Circuits / Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. J Traffic Sig. Above 200 Amps Above 100 Amp:
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
I herebvi certi(v that I insoected the electrical installation described
copy
�J �
-r--'— -�—r---�- Final / " �`�r I �af�.. /
Investigative Fee ` � � � / �� ��
THlS INSTALLATION MAY BE ORDERED D{SCONNECTED IF NOT COMPLETEd WI7HIN 18 MONTHS.
OFFICE USE ONLY This requosf void 18 monfhs 6om validofion dafe prinfed in this box.
��H���II�������������I�������������� � a5. 5z
��
* 0 8 9 2 5 5 9 6 * �7�3
PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? ❑ Yes ❑ No �nspection Ofher Than Rough-In: Ready Now 0 WiII�CoII
� � 2, ��.. V� You must call the inspector when ready Dote Ready: �
I, �licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sfrcef Box, or oufe N� �� City �� � Zip Code
p t c o � �-
Secfion No. Tow ship Name or No. Ranqe No. Fire No. �
Phone No.
. � �9r,��
� Address
y Name _ Gonhacfor License No.
_ ,
r, ompaqy or Owner PerForming Insfallation) J
� i I�f� ����� �'ll ( I� )`�
�acfor, Company or Owner Performinq Insfallafion�
STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF VFI I nW C[1Pv