P - 82433U���62-�31 �
Home Duplex
Commercial Indusfrial
Air Conditioner Htg. Equip.
Dryer Range
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity 3
1821 UniversiTy Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us `'�'
Apt. Bldg. Other: New ddn
Farm Remod Repair
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
"X" above the work covered by tC�_es'�remar� this space nd on the back of the white copy only.
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Calculate Inspection fee - This Inspection Request wiii not be accepted withou� the correct fee:
Other Insfallations fee # Service Enfrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic $ig. Above 200 Amps Above 100 � Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT �--�
Sign / Outline Ltg. Xfmr. — -
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the electrical installation described herein on the dates stated:
Irrigation Boom Rough-In Da�e
Speciallnspecti �- � ��
Final Dafe �
Investigative Fee �
THIS INSTALLATION MAY BE ORDERED DISCO CTED IF NOT COMPLETED WIT N 18 MONTHS.
OFFICE USE ONLY This requast void 18 monfhs from validation date prinfed in this box.
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23315 IP
/ PLEASE PRINT OR TYPE
contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: