P - 82135/ REQUEST FOR ELECTRICAL INSPECTION �
State Board of Electricity � L ``:;
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1 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
651 2-0800 www.electricit state.mn.us
Home � /,� Duplex Apt. Bldg. Other: New
Commercial Industrial Farm Remod
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other.
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
QOTE�Ct � S: 2 �d1 i�
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Calculate Insp�
Other Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Tra nsFormer/Generator
Sign / Outline Ltq. Xfmr
Pool
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Fee - This Inspecfion Request will not be accepted without the correct fee:
# Service Entrance Size Fee # Circuits / Feeders
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL
I hereby certify that i inspected the electrical installation described herein on the dc
Rouah-In TDate
' ' Fi�al Dat
Imestigative Fee � J� �`� Z-
THIS INSTALLATION MAY BE ORDERED DI ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validation date printed in this box.
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PLEASE PRINT OR TYPE
R vesf Data/y� Rough-in inspection required? ❑ Yes � No Inspecfion Ofher Than Rough-In: ❑ Ready Nov� Will Call
�•�O•w � You muet caU the iaspector when reody Date Reody:
I,� licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
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