P - 82579[7
�, 0 1 4_H26 �Q REQUEST FOR ELECTRICAL INSPECTION �.`HE�
, Minnesota State Board of Electricity ��a
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 �_;
� ' �
(651) 642-0800 www.electricity.state.mn.us �:;�5a��
v 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 ihe work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This
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
will not be
`�8���
without the correct fee.
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL
`t'd.�
I hereby certify that I inspected the electrical installation described herein on the dates stated:
Rough In Date
I I Irnestigative Fee I I r����� � j I va`� ��U I
THIS INSTALLATION MAY BE ORDERED D ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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I IIIIII IIIII IIIII IIIII IIIII III IIIII IIII IIII OFFICE USE ONLY T�his request void 18 months irom validation date printed in this box.
*�oya.a o� aC�.�
Request Date
PLEAS �R� OR TYPE �� `� ��
Rough-In inspection required? 0 Yes ❑ Nt7� Inspection Other Than Rough-In: L•� Ready Now 0 Will Call
7 You must call the inspector when ready! Date Ready:
I, [��icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
-- -� �--- a i H i e tsuqhiu GOPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY