P - 80409i�-��67�543 ��
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 �'�'
Home Duplex Apt. Bldg. Other: New n
Commercial Industrial Farm ���� Remod Repair
Air Condifioner 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 copy only.
Calculate Inspe
Other Insrollations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Oudine Ltg. Xfmr.
Alarm/Remote Control
Fee - This Inspection Request wi!! noi be accepted without the correct fee:
# Service Entrance Size Fee # Circuits / Feeders
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL,
��a � 1 hereb certi that I ins ect e electrical installation described herein on the dates siated:
Irrigation Boo Rough-In Date y
Special Inspection F ������
� Final Date ��,d
Investigative Fee --�--
/
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. _�J
OFFICE USE ONLY This requesf void 18 months kom validation date printed in this box.
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PtEASE PRINT TY�E
Request Da �^' Rough-in inspection required? �Yes ❑ No Inspecfion Ofher Than Rough-In: ❑ Ready Now � Will Cali
�'/J ' O� You musf call fhe inspector when ready Date Ready: �
I,�icensed contractor ❑ company ❑ owner hereby request inspection of the above electricpl work at: