P - 81062�
�� 58-350 �2
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
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elect. 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/y.
NSP 3AVER'3 3WCFCH
Ca/culate Inspection Fee - This Inspection Request will not be accepted without the correct fee.
Mobile Home Park Stail
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
Rough In
I inspected the
0 to 100 Amps
Above 100 Amps
TO��
ao.s�
n described herein on the dates stated:
Date
Special InspaC�+or� � E `
Final D� ,
Investigative Fee � �2_ Z— �'d
THIS INSTALLATlON MAY BE ORDERED DIS CTED IF NOT COMPLETED WITHIN 18 MONTHS.
�TM~,���M_�TM���wVrvT.M�.�.� �M���T �.�� OFF�CE USE ONLY This request void 18 months from validatian date printed in this box.
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*08583502* W7
PLEASE PRINT OR TY
Re��t Rough-In inspeclion required? ❑ Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now 0 Will Call
You must call the inspector when ready! Date Ready:
I, ❑ licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY