P - 80228REQUEST FOR ELECTRICAL INSPECTION
�� � � � � � � � � Minnesota State Board of Electricity
1821 University Avenue Suite S•128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us
Home Duplex Apt. Bldg. Other: New
Commercial Industrial Fprm Remc
Air Conditioner Htg. Equip. Wafer Htr. Load Mgmt. Other.
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by Ihis request. Enter remarks in this space and on fhe back of the white
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alculate lnspection Fee - This 1 sp tion equest will not be
Other Installations Fee # Service Enkance Size Fee
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 Control
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Repair
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�pted without the correct fee:
# Circuifs / Feeders Fee
0 to 100 Amps
Above 100 Amps
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on the dafes stated:
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Imestigative Fee -
THIS INSTALLATION MAY BE ORDERED DISC CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 16 months from validation dafe prinfed in this box.
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PLEASE PRINT OR TYPE
Reque �Dglq�� Rough-in inspection required? ❑ Yes No Inspection Other Than Rough-In: ❑ Ready Now Will Call
GYou musf call the inspecfor when ready Date Ready:
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job P�dd s�k Box, or � N� � Ciry �/ �� Zip Code
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Section No. Township Name or No. Range No. Fire No. Coun
Occupant
Power Su�
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Contr tor Lice e No.
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S ATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY