P - 82023REQUEST FOR ELECTRtCAL tNSPECTION
�1 /y� �('�( �',' �. � � Minnesota State Board of Electricity
•� ��,! �J ��.�"' 'r /� 2 1821 University Avenue Suite S-12$ Saint Paul, Minnesota 55104-2993 :
� ( � (651) 642-�800 www.e%ctriciry.state.mn.us "
Home Duplex Apt. Bldg. Other: New Addn
ommercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htc Load Mgmt. Ofher.
Dryer Range Elec. Heat emp, Service
"X" above the work covered by this request. Enter remarks in this space and on ihe back of the white copy only.
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Calculate Inspection Fee - This Inspeciion Reques► will noi be accepted without the correct fee:
Other Installations Fee # Service Enironce Size Fee # Circuits J 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 EjQ (� TOTAL/ �
Sign / Outline Ltg. Xfmr. ,�`,i V !'7 � `� (p �
Alarm/Remote Control
Swimming Pool
I hereb cerTi that I ins ted the electrical insfallation described herein on the dates stoted:
Irrigation Boom Rough-In Date p�
Special Inspection o � r'�
Final D� f� U
nvesfigative Fee ^/
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesl void 18 months From validation date printed in fhis box.
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` PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspection required� ❑ Yes �o Inspection Other Thon Rough-In: ❑ Ready No ill CaII
You must call the inspector when ready Date Ready: �
I, 0licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: