P - 81222U-���-551 �
REQUEST FOR ELECTRICAL INSPECTION
Ma�nesota State Board of Electricity
1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us
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"X" above the work covered by
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Calculate Inspe
Other Installations
Mobile Home Park Stall
Sheet Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xknr.
Alarm/Remote Control
Swimming Pool
irrigation Boom � .
Specia� Inspecti t
copy only.
Fee - This Inspec►ion Reques► will not be accepted wiihou► the correct fee:
# Service Enirance Size Fee # Circuifs / Feeders Fce
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY �(� . S TOTA�
herein
Date
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� � Investigative Fee � � � j� �5 ��� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validation date prinfed in fhis box.
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PLEASE PRINT OR TYPE
contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
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STATE 60ARD COPY
SEE INSTRUCTIONS ON BACK OF YELLOW COPY