P - 80330C�-�89�-561 �
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 I I Duplex I I Apt. Bldg. I Other: I I New
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the bock of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correcf fee:
Other Installations fee # Service Enfrance Size Fee # Circuifs / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL ��p
Sign / Outline Ltg. Xfmr. '
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins cfed the electrical installation described herein on the dates stated:
Irriqation Boom Rouah-In Dare
THIS INSTALLATION MAY BE ORDERED DISCOT�INECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months from validation date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Dafe � Rough-in inspection required? ❑ Yes ❑ No Inspection Other Than Rough-In: eady Now � Will Call
�� a+� ,r�! � You musf call fhe inspecfor when ready Dote Ready:
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.)� City Zip Code
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Section No. Township Name or No. Range No. Fire No. unfy
�� Phone No.
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i` Address
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Confractor License No. I Master Lic. No.
f�If.E{�V �G I (:
mpany or Owner P�rforming Installafion)
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, Company or Owner Performing Ins allafion
STATE BOARD OPY
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SEE INSTRUCTIONS ON BACK OP YELLOW COPY