P - 82186U-�936-�92 �l
:
Apt. Bldg
REQUEST FOR ELECTRICAL INSPECTION `��x� .
Minnesota State Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 ��.
(651) 642-0800 www.electricity.state.mn.us `�'
Commercial Industrial Farm Remod �p Repair
Air Conditione� Htg. Equip. Water Htr. Load Mgmf. Other:
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.
S���R;o� a,5q �5 ��-� �I�.- - � �`'�.�.
Calculate Inspection Fee - This Inspection Request will not be accepted withoui �he correct fee:
Other Installations Fee # Service Enfrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps q`i 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY OTAL,,, .5O
Sign / Outline Ltg. Xfmr. cw� �
Alarm/Remote Control
$Wlmmin9 Poo�, I hereb certi that I ins ted the electricol installation described herein on ihe dates stated:
Irriaation Bodra � A n u.,,Ntii., n��P
� Investigative Fee �" �
THIS INSTALLATION MAY BE ORDERED
l�N II NI � III II I� II III II HI I�II C1�1�
* � 9 3 6 8 9 2 9*
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DISCOI�R�CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinfed in fhis box.
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355�
PLEASE PRINT OR TYPE
Request Date Rough-in inspection required$ ❑ Yes �o Inspection Other Than Rough-In: � eady Now ❑ Will Call
�—a '�—� e You musf call the inspecfor when ready- Dofe Ready:
I, �icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: