P - 80390REQ� S�TtFOR�ELECT� CAL' I�VSP�CTION -_
� (� �� � (� p � � 3 � � Minnesota State Board of Electricity �'3
l.1 11 Q 7821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.elecfricity.state.mn.us
Home Duplex Apt Bldg 01her: New Addn
Commercial Industrial Farm
Air Conditioner Hfg. Equip. Wafer Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on
the white copy only.
Calculate Inspection Fee - This Inspeciion Requesi will not be accepted wiihout the correct fee:
Other Installations Fee # Service Enhance Size Fee # Circuih / Feeders Fea
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 T,�¢jyA1�� �
Sign / Outline Ltg. Xfmr. �lJ�
Alarm/Remote Control
I hereby certify that I
Rough-In
the dates stated:
Special Inspection
finaf �r
Investigative Fee L� Z 7�-Gc'i
THIS INSTALLATION MAY BE ORDERED DISC N CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONIY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Req sf Dafe�� — � Rough-in inspecfion required8 ❑ Yes � No Inspection Other Than Rough-In: R dy Now � Will Call
You must call the inspector when ready Date Ready:
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Shcet, Box, or Route No.! Ciry Zi Code
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Secfion No. Township Name or No. Ranqe No. Fire No. Coynty
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Address �Conhactor,
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or vwner rerrorming msrau ��.„,
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�m any or Owner Performing Instollafion) �� Phone Number
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STATE BOARD COPY SEE INSTRUCTIONS ON BACK �F re�LOw rnav