P - 811150�866-166 �1
A Home Duplex
REQUEST FOR ELECTRICAL INSPECTION -
Minnesota State Board of Electricity 3�
182} UniversiTy Avenue Suite S-128, SaiM Paul, Minnesota 55104-2993 =
(651) 642-0800 www.electricity.state.mn.us ''�'
Commercial Industrial Farm Kemod n
Air Conditioner Hfg. 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 on
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Calculate Inspec�ion Fee - This Inspeciion Request will not be accepted it ou► t e correct fee:
Other Installations Fee # Service Entrance Size Fee # Circuits / feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 Fo 100 Amps
Sireet Lig. / Tra(fic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL _
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I herebvi certifv that I insoected the e
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herein on the dates stated:
- Final / �' 1Uafe� c�
Investigative Fee ( � i L.i ^� 7 C�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTH .
— !�— !� OFFICE USE ONLY This request void 18 months from validation date prinled in this box.
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PLEASE PRINT OR TYPE ,
1, `� licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
IY �7V�V� —�
STATE BOARD COPY
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY