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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us
Apt. Bldg. Other: New
Farm Remod
m� `
Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by this requesi. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
', Other InsTallations Fee # Service Enkance Size Fce # Circuits / Feeders Fee
� 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 TOTAL 5.�
Sign / Outline Ltg. Xfmr. �� Q'� Q �
Alarm/Remote Control V V el
Swimming Pool
I hereb certi that I ins ected the electrical inslallation described herein on the dates stafed:
Irrigation Boom Rough-In Dare
Special Inspection
Final D QG
Investigative Fee —? /—
THIS INSTALLATION MAY BE ORDERED DIS TED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLV This requesf void 18 months from validation date printed in ihis box.
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Request Date Rough-in inspection required? ❑ Yes ❑ No Inspecfion Ofher Than Rough-In: Ready Now ❑ Will Call
s O You must call the inspector when ready Date Ready:
1, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Srreet, Bo� or Roure No.) � Ciry�
_ r Zip Code
Section
(Y1l �I�ov�,
ng Address (Contractor,
�y.
or No.
N� �
� Name
�e
impany or Owner PerForming
1�i� 1.� Z
r, Campany or Owner Perfon
STATE BOARD COPV
.I�tY
No. Fire o. C
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onfracror License No.
G71-8 � a:
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SEE INSTRl1CTIONS ON BACK OF YELLOW C�PV