P - 839505�!��-499 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other:
Commercial Industrial Farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks i this space anc
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on the back of the whiie copy
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Am
Transformer/Generator INSPECTOR'S USE ONLY TOTA
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Conhol
Swimming Pool
I hereb certi fhat I ins ed fhe elechical installafion described herein on the dafes
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THtS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion date prinfed in this box.
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Request D%� Rough-in inspection required? ❑ Yes o Inspection Other Than RougMn: Ready Now ❑ Will Call
/��/�� (You musf call the inspector when ready) Date Ready:
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I, �icensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
1ob Address �S t, Box, or R ute No.) ✓ City� Zip Code
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Section No. Township Name or No. Range No. Fire No. Cou ����
Occupant
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