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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 "�'
Duplex Apt. Bldg. Other: New
Industrial Farm Rem<
Htg. Equip. Water Htr. Load Mgmt. Other:
Range Elec. Heaf Temp. Service
�rk covered by this requesi. Enter remarks in this space and on the back of the white
Repair
copy only.
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Ca culate Inspection Fee - This Inspecti Req st wil not be accepted without the correct fee:
Other Insfallations Fee # Service Entrance Size
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
Swimmin Pool
# Circuits / Feeders
0 to 100 Amps
Above 100 Amps
9 I herebvi certiH that I insoected the elechical installation
the dates stated:
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Investigative Fee ��r �� ""'—� G �-'
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
i� OFflCE USE ONLY This requesf void 18 months from validation date printed in fhis box.
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PLEASE PRINT OR TYPE