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Home Duolex
� "X" above �he work
REQUEST FOR ELECTRICAL INSPECTION " �
Minnesota State Board of Electricity
1821 University Ave., Rm. 5-128, St. Paul, MN 55104
Phone (612) 642-0800 .s�z.- %€
Water Hlr. Load Mgml. O}her:
Elec. Heaf Temp. Service
this requesG Enler remarks in this spoce and on the
Calculate Inspec�ion Fee - This Inspection Reques� wil! not be occepfed wifhou� the correc� fee:
Other Fee # Service Enhance Size Fee S Circuits
Mobile Home Park 51a11 0 to 200 Amps 0 to 100 A
Street Ltg./Traffic Sig. Above 200_Amps Above 100
Tmnsformer/Generaror INSPECTOF'S USE ONLY
3 Pool
Boom
copy only.
Fee
�_ THI5 INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This �equest vmd 18 monlhs fiom validafion dote p�imed in �hls bon.
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� LEASE PRINT OR TYPE
Reques� Dafe.�/ /� Rwgh�in inspxnon requi.ed? ❑ Ye: o Inspenion Olher Than Roogh In: eady Now � Will Coll
� rFip `7 (Yo� most call ihe I�spenor whe� readyl Oo�e Heody:
I, icensed conirocfor ❑ owner hereby requesl inspection of the above ele<Irical work aY.
lob ddress ISrre Box, or �e N G Zi
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