P - 81096-� REQUEST FOR ELECTRICAL INSPECTION
!�� O O�F - 3 3 9�I Minnesota State Board of Electricity
,J 1821 Universiry Avenue Suite S-128, Saint PauL Minnesota 55104-2993 ���
(651) 642-OS00 www.electricity.state.mn.us "�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Form Remod Repair
Air Conditioner Htg. Equip. Water Hir. 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 ihe white copy only.
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Calculate Inspection Fee - This Insp�
Ofher Installations Fee # Service Entrance Size Fee # ircuits / Feeders
Mobile Home Park Stall 0 to 200 Amps 0 ro 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generotor INSPECTOR'S USE ONLY TOTAI!
will not be accepted without the correct fee:
Sign / Outline Ltg. Xfmr.
A4arm/Remote Control
Swimming Pool
I hereb certi that I ins ted the
Irrigation Boom Ro„8�,.�„
Special Insaect r"� �? t�' _'�
the dates stated:
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� � Imestigative Fee "" �" -' /r� � ���� � Q �-'-�' L'
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHiN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from v�rydqfq�fe�n this box.
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PLEASE PRINT OR TYPE
Request Da%� ��� Rough-in inspection requiredZ ❑ Yes No Inspection Other Than RougMn: eady Now ❑ Will Cal)
You musf call the inspector when ready Date Ready:
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: