P - 82184REQUEST FOR ELECTRICAL INSPECTION �a�
Ur Q1�C G�� C'I � Minnesota State Board of Electricity �
... J V ..J .L 1821 University Avenue Suite S-128, SaiM Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us �n� ��"
Home Duplex Apt. Bldg. Other: New Addn
C mercial Industrial Farm Remod Repair
ir Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" pbove the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate lnspecfion fee - rhis InspectrdFi Request wdl not be accepied withoui ihe correct fee:
Ofher Installafions 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 1tg. Xfmr. � . �
Alarm/Remote Control
Swimming Pool
_ I herebvi ceAifv fhof I insoecfed fhe elecfrical installation described herein on the dates sfofed:
Date
� � Investigative Fee � � � _�_�f____._� ��'-`U —�C�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This raquest void 1 S months from validation date prin}ed in this box.
Illif N��I�I�IIIIIIIII��IIIII�1 �rr � .�
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�09562513� �J`��
PLEASE PRlNT OR TVPE
contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY