P - 82315.��=9���-39� �
Home Duplex
Commercial Industrial
Air Conditioner fg. Equip.
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
Apt. Bldg. Other: New
Farm Remod
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
� ��p
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy
%e� r� n �� Ft�.r n �...�
Calculate Inspection Fee - This Inspection Request will not be accepfed without fhe correct fee:
Other Installations Fee # Service Enhance Size Fee # Circuits / 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
n / Outline Ltg. Xfmr.
rm/Remote Control
imming Pool
�ation Boom
�ciallnspecf�`�nC117 ,
I inspecfed the
dafes
Repair
Investigative Fee � � � I `� � Z6 —GZ�-
THIS INSTALLATION MAY BE ORDERED DISC NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validafion dafe prinfed in fhis box.
I�ii�����II�I����II��I�iIN�I�IIi�H���ll�l� s �/°,�
* 0 9 8 8 3 9 1 9 * �(6a
PLEASE PRINT OR TYPE
Request Dafe � Rough-in inspection required? ❑ Yes ❑ No Inspection Other Than Rough-In: Ready Now ❑ Wili Call
�"�'��' You musf call the inspecror when ready Date Ready:
I,�icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: