P - 81102REQUEST FOR ELECTRICAL INSPECTION
U����� 17 5� Minnesota State Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ���
. (651) 642-0800 www.electricity.state.mn.us "�'
Home Duplex Apf. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Hfg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by this re uesf. Enier remarks in fhis space and on ihe back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepied wi out the correct fee:
Other Instal{alions Fee # Service Enhance Size Fee # Circuifs / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps ,pQ ,0{
Sireet Lfg. / Traffic Sig. Above 200 Amps Above 100 Amps
TransFormer/Generator INSPECTOR'S USE ONLY TOTAL
Sig� / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimminq Pool
described herein on the dates sfafed:
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Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISC CTED IF NOT COMPLETED WIT IN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from volidation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required? ❑ Yes No Inspecfion Ofher Than Rough-In: ❑ Ready Now Will Call
Z.� q�� You must call the inspector when ready Date Ready:
I, �licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
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