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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity �� �� 3
1921 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 �;
(651) 642-0800 www.electricity.state.mn.us '���
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Condifioner Htg. Equip. Water Htr. Load Mgmt. Other: ,
Dryer Range Elec. Heat Temp. Service r
"X" above the work covered by this request. Enter remarks in this space d on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Reqvest will not be accepied wifhout the correc► fee:
Other 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 TOTAL
$ign / Outline Ltg. Xfmr. Q � ��
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the electrical installation describad ha�ein on the dates stated:
Irrigation Boom Rough-In Date
Special Inspecti -��
Firml Date
Investigative Fee �-
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFfICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
2 5/1999
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STATE BOARD COPY
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY