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Home Duplex
Commercial Industric
REQUEST FOR ELECTRICAL INSPECTION �
� Minnesota State Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us "�'
Farm
New
Remod
Air Condifioner Htg. Equip. Water Hir. Load Mgmf. Ofher:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the whi►e
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Calculate inspection fee - This Inspection Request will not be accepted wiihout the correct
Other Insfallations Fee # rvice nfrance Size Fee # Circuits / Feeders
Mobile Home Park Stall 0 to 0 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amp
Tra nsformer/Generator
Sign / Outline Ltg. Xfmr
Alarm/Remote Control
Swimming Pool
Irriqation Boom �1 /
INSPECTOR'S USE ONLY
hereby certify that I inspected the elechical
Rough-In
copy
fee:
Fee
s�
a�
dares stafed:
rinal / ' f� I � //�Q.�f I
Investigative Fee �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in fhis box.
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* 0 9 6 2 2 2 8 3* ��0�
PLEASE PRINT OR TYPE
Requesf Date � Rougffin inspecfion required$ ❑ Yes ❑ No Inspection Other Than Rough-In: eady Now ❑ Will Call
You must call fhe inspecfor when ready Date Ready:
I,,�jcensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: