P - 82158REQUEST FOR ELECTRICAL INSPECTION �°'E
C� -�� Cl - 5 5 9� Minnesota State Board of Electricity �� �
_J' 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 ���:
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(651) 642-0800 www.electricity.state.mn.us ��•
Home Duplex Apt. Bldg. Other: New Add --
Commercial Industrial Farm Remocl epair
Air Conditioner Htg. Equip. Wafer Htr. Load Mgmt. Ofher:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesi. Enter remarks in this space and on the back of the white copy only.
Seal cut and repair meter socket
Calculate Inspe
Other Installations
Mobile Home Park Stall
Streef Ltg. / Traffic Sig.
Tra nsformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irriaation Boom
Fee - This Inspection Request will not be accepted without the correct fee:
# Service Entrance $ize Fee # Circuits / Feeders Fee
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL
20.5�
on
rma / � _ vaf ��
Investigative Fee c ,
THIS iNSTALLATION MAY BE ORDERED DISCONNECTED tF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validafion date printed in this box.
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* 0 9 1 8 5 5 9� � �l�° a
PLEASE PRINT OR TYPE
Request Date Rough-in inspection required$ ❑ Yes �No Inspection Ofher Than Rough-In: � Ready Now ❑ Will Call
,rj-12—�� You must call the inspector when ready � Date Ready:
1, �icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: