P - 81564REQUEST FOR ELECTRICAL INSPECTION °'E�°
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Minnesota State Board of Electricity
s � 1821 University Avenue Suite S-128, Saint Paul, Mlnnesota 55104-2993 -
� (651) 642-0800 www.electricity.state.mn.us � "�'
ome Duplex Apt. Bldg. Oiher. % �/ New Jdn
Commercial Industrial Farm �QYJ(� Q. Remod �tepair
Air Condifioner Hfg. Equip. Wafer 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.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Ofher Installaiions Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps ro0
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T A �r
Sign / Outline Ltg. Xfmr. 0'' J�
Alarm/Remote Control
Irrigafion Boo RougMn ��
Special Inspe p
Final
Investigative Fee � "'�--�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validaf' �fe prinfed in fhis box. ,
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PLEASE PRINT O TYPE
Re uest Date Rough-in inspection required2 ❑ Yes o Inspecfion Other Than Rough-In: eady Now � Will Call
t� �$i Q� You musf call fhe inspecfor when reody Dafe Ready: // � b'/� � O
I, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: