P - 84520REQUEST FOR ELECTRICAL INSPECTION � ��E�,,,���
" � EB-00001-09
-'' ��� See instructions for completing this form on back of yellow copy. �'
r'� 9 9�� 'X" Below Work Covered by This Request .;�r ,��
New Add Rep. Type of Building Appliances Wired Equipment Wired
Home Range Temporary Service
Duplex Water Heater Electric Heating
Apt. Building Dryer Load Management
Comm./Industrial Furnace Other (Specify)
Farm Air Conditioner
Other (specify) Contractor's Remarks:
Compute lnspection Fee Below:
# Other Fee # Se ice Entran e Size Fee # Circuits/Feeders Fee
Swimming Pool 0 to 00 Amps 0 to 100 Amps
Transformers Above 200 Amps Above 100 Amps
Signs Inspector's UseAnly: � � � TOTAL
Irrigation Booms �yyjb � 4 � �/ �
Special Inspection J
Alarm/Communication THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT
Other Fee COMPLETED WITHIN 18 MONTHS.
I, the Electrical Inspector, hereby Rough-in Date
certify that the above inspection has
been made. F'"� �a
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OFFICE USE ONLY . �
This request vad 18 months from
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0-19�-974,,,� �. � �..
�Request Date Fire No. Rough-In Insp�n Required Inspection ,.,er Than Ro�h-In�
�/ .� (You maust call inspectorOwhNoready) dy Now � Will Notiiy Inspector
j �es Date Ready
I fi ensed contractor ❑ owner hereby request inspection of above electrical work at:
Job Address (Street, Box or Route No. � City� � e
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Secti No. ownship ame o� No. Range No. County
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Occupant (PRINT) ���JJJ---
V � � �� / � D � Phy� No. / ��,\
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Power Supplier Addr s
� s' CS �a�t.rrl � �1
Electrica� Contractor (Company Nam ) �.-- Contractor's License No.
4 Rt� t� ��rb �2��
Mailing Address (Contractor or er Makinp Ipstallation)
2� �3 � �;�.�s v s�� �,�' f� /���� ..c.t..�
Authorized ' re (Contract O ner Making Installation) �� O Phone Number ���
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MINNESOTA STATE BOARD OF ELECTpI ITY THIS INSPECTION REQUEST WILL NOT
Griggs-Midway Bldg. - Room 5-128 I IIII II I�I I� � IIIII IIIII IIIII IIIII II �II IIIII IIIII gE ACCEPTED BY THE STATE BOARD
1821 University Ave., St. Paul, MN 55104 jN N N UNLESS PROPER INSPECTION FEE IS
PMone (612) 642-0800 ENCLOSED.