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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 �-
(651) 642-0800 www.electricity.state.mn.us "'
Home Duplex Apt. Bldg. Other:
�`ommercial Industrial Farm
Air Condifioner 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
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Calculaie Inspection Fee - This Inspec n Request will nof 6e
Other Installations Fee # Service Enhance Size Fee
Mobile Home Park Stall 0 to 200 Amps
Street Ltg. / Traffic Sig. Above 200 Amps
Transformer/Generator INSPECTOR'S USE ONLY
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
_ �_ I herebvi certify that I inspected fhe elecfrical i
Repair
white copy only.
� without the correct fee:
Circuits / Feeders Fee
0 to 100 Amps
Above 100 Amps
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G�%
on the dates stated:
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Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validation dafe printed in fhis box.
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PLEASE PRINT OR TYPE
contractor ❑ company ❑ owner hereby request
of the above electrical work at:
SEE INSTRUCTIONS ON BACK OF YELLOW COPY