P - 80400,
(��901-636 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity ':3
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us "�'
Home Duplex Apt. Bldg. Other:
Commercial Industrial Farm
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. Service
"X" above the w k c�by this request. Enier remarks in this space
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Calculate Inspection Fee - This Inspecfion Request will not be a
Otherinstallations Fee # Service Enhance Size fee
Mobile Home Park Stull 0 to 200 Amps
Street Ltg. / Traffic Sig. Above 200 Amps
Transformer/Generator INSPECTOR'S USE ONLY
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimmin Pool
on the back of the white copy only.
� without the correct fee:
Circuits / Feeders Fee
0 to 100 Amps L
Above 100 Amps
TOTAL
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9 I herebvi certiH that I insoected the electrical installation described herein on fha dates stated:
Investigative Fee r�� a � I u��" ��--Q�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN i8 MONTHS.
OFFICE USE ONLY This request void 18 months kom validation dafe prinfed in fhis box.
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* 0 9 0 1 b 3 6 1 * ����
PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required$ ❑ Yes �lo � Inspection Ofher Than Rough-In: �i Ready Now 0 Will Call
.� � L S� � You musf call fhe inspector when reody Dafe Ready:
1, �licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: