P - 82145� s -
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REQUEST FOR ELECTRICAL INSPECTION �
(� � g � r� � � � � � Minnesota State Board of Electricity ��
a
� � 7821 Un+versity Avenue Suite S-128, SaiM Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us `3��
Home Duplex Apt. Bldg. Other: New Addn
Remod
Air Conditioner I +Htg. Equip. I I Water Htr. I I Load Mgmt. I Other:
Dryer ' I Range r Elec. Heat Temp. $ervice 1
"X" above the work covered by this requesf. Enfer remarks in this space and on the back of the white copy
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Installa+ions Fee # Service Enhance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Tronsformer/Generptor
Sign / Outline Ltq. Xfmr.
0 to @�mps 0 to 100
Above 200 Amps Above 1(
INSPECTOR'S USE ONLY
that I insoecfed the elechical
Repair
�
�
L 1lnvestigative Fee � �! ������� I U°� 2 Z—C3�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months 6om validallon dafe printed in this box.
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* 0 8 9 2 6 2 2 2* �l '
PLEASE PRINT OR TYPE
Request Date Rough-in inspeclion required? ❑ Yes ❑ No Inspecfion Other Than Rough-In: Ready Now � Will Coll
� "�� Q Q You must call the insp�ctor when ready Dote Ready: � �
1, (�licensed contractor� compony ❑ owner hereby request inspection of the above electrical work ah
STATE BOARD COPY
SEE INSTRUCTIONS ON BACK OF YE6lOW COPY