P - 82289REQUEST FOR ELECTRICAL INSPECTION • �
U�� J�-� 2 9�l Minnesota State Board of Electricity
1821 Universiry Avenue Suite S-728, Saint Paul, Minnesota 55104-2993 i�i
�' (651) 642-0800 www.electricity.state.mn.us `'�'
.$o � �' Icr,cc�s� � ��7 — � ��S
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Ofher Instaliafions Fee # Service Enhance Size Fee # Circuih / Feeders Fee
Mobile Home Park Stalf 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Troffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr. �d / 5d
Alarm/Remote Control
����� I hereb certi that I ins cted the elechicol installation described herein on the da�es
BOOm Rouah-In Date
I � lnvestigative F�'� U +G !�/ � `....�. � _�� ` � ,% J ^ ° %
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This reques6void 18 monfhs from validatian date printed in this 6ox.
I��IIIIIIIIIII(ill��l�l��l�Illlll�ll +�r a°��
* 0 9 5 4 5 2 9 4*
4�q��
PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required$ ❑ Yes No �nspection Ofher Than Rough-In: ❑ Ready Now Will Call
��'I q'��O You must call fhe inspecfor when ready Dafe Ready:
I, 0 licensed contractor ❑ company ❑ owner hereby request inspection of the above electrica{ work at: