P - 82248�=014-829 �4 REQUEST FOR ELECTRICAL INSPECTION �" °
Minnesota State Board of Electricity 3
.' 1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 _ -
(651} 642-0800 www.electricity.state.mn.us
Home Duplex Apt. Bldg. Other: New Addn
Commerciai Industrial farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elect. Heat Temp. Service
X" above the work covered by this request. Enter remarks in this space and on the back of the white copy on/y.
Ca/culate Inspection
�ther Installations FE
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
NSP �AVER'� �WITGH
Fee - This Inspection Reauest will not be
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
Rough In
without the correct fee.
�ircuits / Feeders
0 to 100 Amps
Above 100 Amps
TOTAL
2Q.r'J�
installation described herein on the dates
Special inspe�i '
Final Date
Investigative Fee - Z 3- Q
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
..__._.���.•_•�.•..•�.•�.•__•_•�,•_.�_._.___._.�_._,_._.s.,__._._._._._....�_•_•�•_•_•_•_-•�,__•.-._.��.� ................. .. ..
III�II I�II� I��I� ����I IIIII II I���) II�I ��I� OFFICE USE O�ILY This request vad 18 months from vaiidation date printed in this box.
� �O' . N
*1 07 48 4* � L�l��/
PLEASE PRINT OR TYPE
Request Date Rough-In inspection required? � Yes ❑ N� Inspection Other Than Rough-In: � Ready Now ❑ Will Call
You must call the inspector when ready! Date Ready:
I, [jQicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: