P - 82042REQUEST FOR ELECTRICAL INSPECTION �
U � � � � � /1� � � � Minnesota State Board of Electricity ���'
�T 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 Addn
Commercial Industrial Farm � Remod Repair
Air Conditioner Htg. Equip. Water Hir. Load Mgm Other:
Dryer Range Elec. Heat Temp. Service
"X" above rhe work covered by ihis request. fnier remarks in this space ond on the back of the white copy only.
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Calculate Inspection Fee - This Inspecfion Request will not be accepte�d w�thout the co�fee.•��
Other Insfallations fee # Service Enirance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall ( 0 to 200 Amps O��' 0 fo 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Tra nsformer/Generator
Sig� / Outline Lt9. Xfmr.
Alarm/Remote Control
Swimmina Pool
INSPECTOR'S USE ONLY
I herebvi certifv that I
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the electrical insfal6
3o�Sa
the dates stated:
� Investigative Fee � � � ���–' ����—C�z>
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months kom validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion raquired$ ❑ Yes �o Inspection Ofher Than Rough-In: �ady Now Q Will-Call
3�.��� � Q You musf call the inspecfor when ready Date Ready:
1, �°licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: