P - 80262�1-89�-927 �
REQUEST FOR ELECTRICAL INSPECTION -
Minnesota State Board of Electricity 3
1821 University Avenue Suite 5-128, Saint Paul, Minnesoia 55104-2993 ��;
(651) 642-0800 www.electricity.state.mn.us " '
e Dupfex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. $ervice
"X" above the work covered by this request. Enter remarks in ►his space and on the back of the white copy only.
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Calculate Inspec►ion Fee - This Inspection Request will not be accepted wi►hou► the correct fee:
Other Installations Fee # Service Enhance Size Fee # Circuifs / Feeders Fee
Mobile Home Park Stall % 0 to ;� -� / 0 to 100 Amps °l �"
Streef Lig. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr. , �
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the electrical installation dexribed herein on the dates stated:
Irrigation Boo Rough-In Dare
Speciallnsp C�
. Final Dale . � l�1��
Investigative Fee "�•���
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
.. OFFICE USE ONLY This request void 18 months (rom validation dafe printed in this box.
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PLEASE PRINT OR TYPE
Request Daie Rough-in inspection required$ ❑ Yes o Inspection Ofher Than RougMn: ❑ Ready Now ill Call
f"� -'� You musf call the inspecror when ready Date Ready:
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: