P - 80404REQUEST FOR ELECTRICAL fNSPECTION °�
^y�7p{�/ /�� Minnesota State Board of Electricity °i
U� V V�1' - 413 � 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us `���
"X" above the work covered by
CalEulate In�p�ecf� Fee �TFiis-Insp�t ^dn Reque�.. %ill
7'
Other Instailations Fee # Service Entrance Size
Mobile Home Park Stall 0 to 200 Amps
Street Ltg. / Traffic Sig. Above 200 Amps
TransFormer/Generator INSPECTOR'S USE ONLY
Sign / Outline Ltg. Xfmr.
Alarm/Remote Conhol
Swimminq Pool
1 Investigative Fee �
THIS INSTALLATION MAY BE
white copy only.
`G ��J �i'
not be accepted without the correct fee:
Fee # Circuits / Feeders Fee
0 to 100 Amps
Above 100 Amps
TO��I �
1 hereby certify that I inspected the electricai installation described herein on the dates
Rouah-in - � -� D�e
)ERED DISCONNE�D IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months From validafion date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Request Date�/�'�� Rough-in inspection required? ❑ Yes No Inspection Ofher Than Rough-In: ❑ Ready Now Will Call
� You must call the inspetlor when ready Date Ready:
I, �censed contractor ❑ company ❑ owner hereby request inspection oF the above electrical work at: