P - 82121REQUEST FOR ELECTRICAL INSPECTION �
�`� � � 1 Q � � � � � Minnesota State Board of Electricity _
� 61 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us "�'
e.
Home Duplex Apt Bldg. Other: New Addn
Commercial Indusfrial Farm Remod Repair
Air Conditioner Hig. Equip. WaYer Fftr. 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.
Panel Change & CAC prewire Seal Cut
Calculate Inspection Fee - This Inspection Request will not be accepied without ihe correct fee:
Other Installations Fee # Servic Entrance Si Fee # Circuits / Feeders Fee
Mobile Home Park Stall 1 0 to 00 Amps 30. 00 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr. 30.50
Alarm(Remote Control
Swimming Pool
I hereb certi if�at I ins ed the elechical installation dexribed herein on the dates stated:
Irrigation Bo ��� � �` t" Rough-In ��
Special Inspection
Final
Investigative Fee �
THIS INSTALLATION MAY BE ORDERED DISCONNEC7ED IF NOT COMPLETED WITHIN 18 MONTHS.
�_ OFFICE USE ONLY This requesf void 18 months from validation date printed in this box.
�1���������l���lli�lll��q����� � 30-�
* 0 9 1 8 5 4 2 2 * °�7O°�
PLEASE PRINT OR TYPE
Requesf Date Rough-in inspecfion required2 ❑ Yes � No Inspecfion Other Than RougMn: �i] Reody Now ❑ Will Call
(F �'L7! �� You must call the inspecror when ready Date Ready:
1, �licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: