P - 81638��y76-914 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity ��L�
1821 University Avenue Sui[e S-128, Saint Paul, Minnesota 55104-2993 ��`
(651) 642-0800 www.electriciry.state.mn.us
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusirial Farm Remod Repair
Air Condifioner Hig. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by this request. Enter re rks in ►his space and on the back of the white copy only
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Calculate Inspeciion Fee - This Inspection Request will not be accepied wifhout the correcf fee:
Other Installations Fee # Service Enirance Si e Fee # Circuifs / 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 TOTAJ� ��
Sign / Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the eleclric ' Ilation described herein on the dates stated:
Irri9ation Boom Rough-In Dare
Special Inspection ` ��—��
Final �-.
Investigative Fee ,-���
THIS INSTALLATION MAY BE ORDERED DiSCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months 6om validafion dafe printed in ihis box.
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PLEASE PRINT OR TYPE
R� st Da Rough-in inspecfion required? �es ❑ No Inspecfion Ofher Than Rough-In: ❑ Ready Now Will Call
v! You must call the inspecfor when ready Date Ready:
I, � licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: