P - 82225(�P��937-8�5 �
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 `��'
�-lome Duplex Apt. Bldg. Other: New
Commercial Indusirial Farm Remod
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Ofher:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter 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 Installations Fee # Service Entrance Size Fee # Circuits / Feeders 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 TOT
Sign / Outline Ltg. Xfmr. ��
Alarm/Remote Control
Swimmina Pool _ _ . . .
Special ln'1'�i�efidd �
Final Da 2 ��
Investigative Fee - '7�
THIS INSTALLATION MAY BE ORDERED DiSCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void I B months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Date Rough-in inspection required8 ❑ Yes �No Inspection Other Than RougMn: ❑ Reody Now ill Call
� �OO You m�st call fhe inspector when ready Date Ready:
I, �Jlicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
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