P - 81691����5�-930 �l
REQUEST FOR ELECTRICAL INSPECTION ��
Minnesota State Board of Electriciry 3
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ���
(651) 642-0800 www.electricity.state.mn.us `���
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Calculate Inspection Fee - This
Other Installafions fee # :
Mobile Home Park Stall
will not be
Street Ltg. / Traffic Sig. Above 200 Amps
Transformer/Generator INSPECTOR'S USE ONLY
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
� without the correct fee:
�ircuits / Feeders Fee
0 to 100 Amps
Above 100 Amps
TOTAL
�S. so
that I ins ted the elechical installation described herein on the dates stafed:
Dafe
Investigative Fee Ftoal �� I pa�`z� �� I
THIS INSTALLATION MAY BE ORDERED DI NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation date prinfed in this box.
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PLEASE PRINT OR TYPE
Requesf Dale Rough-in inspection required$ ❑ Yes � No Inspection Ofher Than Rough-In: Ready Now ❑ Will Call
�'� �� You musf call the inspecfor when ready Date Ready:
1, (�licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
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