P - 81208U-��7-719 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity 3
1821 University Avenue Suite 5-728, Saint Paul, Minnesota 55104-2993 -
(651) 642-0800 www.electricity.state.mn.us
Other: New Addn
( ommercial Indusirial Farm
Air Conditioner Hig. Equip. Water Htr. Load Mgmf. Other:
Dryer Range Elec. Heat Temp. Senice
"X" above the work covered by this request. Enter remarks in this space and on
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Repair
the white copy only.
Calculate lnspeciion - This Inspecfion Request will not be accepied wifhoui the correct fee:
Other Installations Fee # Service Enhance Size Fee # Circuits / Feeders Fee
Mobile Home Pork Stpll 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Si . Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT���
Sign / Outline ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereby certify that I inspected the electrical installation described herein on fhe dafes stated:
I I Investigative Fee � ���.�. ��,�-� � � - i�— �"- G� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from volidation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required$ ❑ Yes ❑ No Inspection Other 7han Rough-In: Ready Now 0 Will Call
' a ' g You musf call the inspecfor when ready Dofe Ready: �
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo Address (Sheet, Box, or Roufe Ciy � Zip Code
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Section No_ 7ownship Name a No. Range No. Fire o. County � �
� Power Supplier
Name
ELECTR►C. ,ruc
or ,P ng Insfallation)
IN 55433
nv or Owner PerFormina.ln Ila
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STATE
Phone No.
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Conhactor License No. Master Lic. No. (Planf Elect Only)
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,�j Phone Number
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SEE INSTRUCTIONS ON BA W COPY