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REG2UEST FOR ELECTRICAL INSPECTION -
Minnesota State Board of Electricity
1821 University Avenue Suite S-128, Saini Paul, Minnesota 55104-2993 �i
(651) 642-0800 www.electricity.state.mn.us
Apt. Bldg. Other: New Addn
Farm Remod Repair
Water Hir. Load Mami. Other:
r I Dryer I I Range I I Elec. Heaf I I Temp. Service I
"X" above the work covered by this reque . Entei remarks in this space and on the back of the white copy only.
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Calculate I spection ee -�s Insp tion Reque wil not be accep► without ►he correct fee:
Other Installations Fee # Service Entronce Size Fee # Circuifs / Feeders
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 TOTAL,
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irrigation Boom
Soecial Inspecti�D G
I herebvi certiH that I insoected the elechical
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nna� � _ � �
Investigative Fee '
THIS INSTALLATION MAY BE ORDERED DISC ED IF NOT COMPLETED WITHIN 18 MONTHS.
� OFFICE USE ONLY This request void 18 months from validation daffi prinied in fhis k�ox.
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PLEASE PRINT OR TYPE
contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
SEE INSTRUCTIONS ON BACK OF YELLOW COPY