P - 82390(��'950-938 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity �
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ��
(651) 642-0800 www.electricity.state.mn.us `'�'-
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Hig. Equip. Wafer Htr. Load Mgmf. Ofher:
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.
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Calculate Inspec►ion Fee - This Inspection Request will not be accepted without the correct iee:
Other Installations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Am s
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
TransFormer/Generator INSPECTOR'S USE ONLY TOTAL �/-�
Sign / Outline Ltg. Xfmr. /�� Q J �
Alarm/Remote Control /�'�" `�
$Wimmin9 Poo� I hereb certi that I ins ted fhe elechical installation described herein on the dafes stated:
Irrigation Boom Rough-In Dare :
Special Inspecti
y�� Da
Investigative fee d � � ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY � This requesf void 18 monfhs from validation dafe prinfed in this box.
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* 0 9 5 0 9 3 8 1* �
PLEASE PRINT OR TYPE
Requesf Date �+� Rough-in inspecfion required? �� ❑ Yes o Inspection Other Than Rouglrin: �J:eady Now 0 Will Call
You must call the inspector when ready Date Ready:
I, �licensed contractor ❑ company ❑ owner hereby request inspection of the above elechical work af: