P - 80363i=89�-448 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us
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Commercial Industrial farm Remod Rep
Air Conditioner Htg. Equip. Water Htr, Load Mgmt. Other:
Dryer 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 co y only.
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Calculate Inspecfion Fee - This Inspection Request will not be accepted without the correct fee:
Other Installations fee # Service Entrance Size fee # Circuiis / Feeders Fee
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Tra nsformer/Generator
Sign / Outline Ltg. Xfm�
Alarm/Remote Control
Swimming Pool
Irriaation Boom
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amp,
INSPECTOR'S USE ONLY TOTAL
on the dates stated:
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THIS INSTALLATION MAY BE ORDERED DISCO ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months From validation date printed in this box.
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2�" v�+CEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required$ ❑ Yes ❑ No Inspection Ofher Than Rough•In: eady Now ❑ Will Call
3�. 1� — Q� You must call the inspecror when ready Date Ready:
I, �licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: