P - 80256,-
���88�-139 �
Dryer � � Range
REQUEST FOR ELECTRICAL INSPECTION °
Minnesota State Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 �: -
(651) 642-0800 www.electricity.state.mn.us "��
Apt. Bldg. Other:
Farm
Water Hfr. Load Mgmf. Ofher:
Elec. Heat Temp. Service
is request. Enter remarks in this space and on
New Addn
Remod Repair
copy
�j�b�p (...�a:u.S�lr� [�6l-l�� �'143�5
Calculate Inspection Fee - This Inspection Request will no� be accepted without the correct fee:
Other Installations Fee # Service Enhance Size Fee # Circuits / Faeders Fee
Mobile Home Park Stall 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.
AlarmJRemote Control
Swimming Pool r �
I hereb certi I ins the esc i in on the s s
Irrigation B Ro h-u�i!_�
�� OFFICE USE ONLY This requesf void 18 monfhs 6om validation date printed in this box.
� 'a�' �5�
�������IIi����N������ -�l0
* 0 8 8 6 1 3 9 5*
PLEASE PRINT OR TYPE
Request Date � Rough-in inspection required? ❑ Yes o Inspection Ofher Than Rough-In: ❑ Ready Now ill Call
t"" `� —� You musl cali the inspecror when ready Date Ready:
1, �licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: