P - 82074REC�UEST FOR ELECTRICAL INSPECTION
0-859-$01 � Minnesota State Board of Electricity _
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.e/ectricity,state.mn.us
x Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elect. Heat Temp. Service
X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate lnspecti<
�ther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irriaation Boom
NSP SAVER'S SWITCH
Fee - This InsDection Repuest wil/ not be
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
Speciallnspect' ' '�' "
Investigative Fee Finai
THIS INSTALLATION MAY BE OR
I Illill illli II(il 11111 IIII! IIlII�I�II! III( Illi
*osssso�3*
without the correct fee.
Circuits / Feeders Fee
0 to 100 Amps
Above 100 Amps
TOTAL
-�+�c�'
�. �
that I inspected the electrical installation
Date
� ��f' � --�, 2�.�--Gz
tED SCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
OFFICE USE OMLY This request void 18 rtronths from validaiion date prinled in ihis box.
� �-�
ay��
PLEASE PRINT OR TYPE
Request Date Rough-In inspection required? � Yes 0� Inspection Other Than Rough-In: C�leady Now � Will Call
n. rw . �nn You must call the inspector when ready! Date Ready:
I, g] licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: