P - 80778_ ��
REQUEST FOR ELECTRICAL lNSPECTION �` ° �
0=854-586 �5 Minnesota State Board of Electricity � -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
� (651) 642-0800 www.e/ectricity.state.mn.us
Home Duplex Apt. Bitlg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Co�ditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elect. Heat Temp. Service
X" above the work coverec! by this request. Enter remarks in thrs space and on the back of the white copy on/y.
NSP SAVER'5 �MTCH tNSTALVAT?ON
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee.
0ther Installations Fee # Service Entrance Size Fee # Cirouits / 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 a(,�,�
Sign / Outline Ltg. Xfmr. �;�
Alarm/Remote Control
Swimming Poo
Irri ation Boom � hereby cert' that I ins cted the electrical installation described herein on the dates stated:
9 Rough In Date
�' � Invest+gative Fee � ' � � � �. �F �� Z S ^�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFlCE USE OWIY This request void 18 montlis hom validation date printed in this box.
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0854586&
Request Date "`"' •P1'�'�•'��"
Rough-In inspection required? ❑ Yes � No Inspection Other Than Rough-In: 0 Ready Now ❑ Will Call
You must call the inspec[or when ready� Date Ready: x
I, [�licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
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