P - 82519� REQII,�ST FOR ELECTRICAL INSPECTION �
��"(� � � � � � � � Minnesota State Board of Electricity '�:3
�� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55704-2993
� (651) 642-0800 www.electricity.state.mn.us '� '
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Calculate Inspection Fee - This Inspection Request will noi be accepted without the correct fee:
Other Installations Fee # Service Enirance Size Fee # Circuits / Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic $ig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr
Alarm/Remote Control
Swimmina Pool
Rough-In
that I
ao .�a
the electrica! insrollofion described herein on the dates
Date
0
Investigative Fee r��a� � ����_ l uore���/� QO
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This reqwst void 18 monihs from validation date printed in this box.
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* 1 0 0 3 3? 4 4* a0, S�
PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection required$ ❑ Yes No �nspection Other Tha}' Rough-In: Ready Now ❑ Will Call
/D `�/� You must call the inspeMor when ready Date Ready: /d /�`/6 d
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I,� licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: