P - 82316�°CJ''��-673 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55704-2993 ��`
(651) 642-0800 www.electricity.state.mn.us " '
Home Duplex Apt. Bidg. Other: New Addn
�ommercial Industrial Farm Remod
4ir Conditioner t. Equip. Water Htr. Load Mgmt. Other:
�ryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy
Calculate Inspection Fee - This Inspection Request will not be accepted without ihe correct fee:
Other Installations Fee # Servic Enhance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall ps 0 to 100 Amps
Sfreet Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T
Sign / Outline Ltg. Xfmr. /
Alarm/Remote Control
Swimming Pool
i hereb certi that I ins ted the elechical insfallafion described herein on the dafes sfated:
Irri9ation Boom Rough-In Date y,}�^�
Special Inspe � ��
Final D / Q�
Investigative Fee S
THIS INSTALLATION MAY BE ORDERED DISCO TED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requestvoid 18 monfhs from validafion dafe prinfed in fhis box.
I�I�����I�I�I��������II����III�IN�fll�l���l • �/�/'�2
* 0 9 3 8 6 7 3 1* �l(o�
PLEASE PRINT OR TYPE
� � � Rough-in inspecfion required? es ❑ No Inspection Ofher Than Rough-In: ❑ Ready Now Will Call
You must call the inspector when ready Date Ready:
I,�,licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
.