P - 82629�-9�76-999 �
Home
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us
Other: New
�ommercial Industrial Farm
4ir Con er Htg. Equip. Water Htr. Load Mgmt.
�ryer Range Elec. Heat T Service
"X" above the work covered by this request. Enter remarks in
� �,� t� � P�-� ��C-
��..
��.�,� �
�
;;�e
Addn
his space and on the back of the white copy only.
� f=u rr��a%��
Calculaie Inspection Fee - This Inspection Request will nof be accepted wifhout the correct fee.
Ofher Installations Fee # Service Entrance Size Fee # Circuits / Feeders
Mobile Home Park Stail 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
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Fee
s�
._ _ � I hereby cerfify thaf I inspecfed fhe electrical installation described herein on fhe dafes sfated:
D
Date
Special Inspe�tibd
Fineh Dare
Investigative Fee 7--� `l' �j"r
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation dafe prinied in ihis box.
IIIIIIIIIIIII�iIIIIiIIIIIIIIII�III1Clll�l�ll +�► a� .�
� 0 9 7 6 9 9 9 3* ����
PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? ❑ Yes ❑ No Inspection Other Than Rough-In: �eady Now ❑ Will Call
' --� �—�� You musf call fhe inspector when ready Dafe Ready:
I, �licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: