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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.e/ectricity.state.mn.us . ''
'X" above the work covered by this reque.°��ter remarks in this space and on the back of the white copy only.
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Calculate Ins ection Fee - This Inspection Request will not be accepted without the correct fee.
Other Installations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stalt
Street Ltg. I Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Irrigation
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
I hereby certi(y that I inspected the �
Rough In
0 to 100 Amps
Above 100 __
TOTA�,, ^
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Date
Investigative Fee � � � I oa�l�� `p,� I
THIS INSTALLATION MAY BE ORDERED ECTED IF NOT COMPLETED WITHIN i8 MONTHS.
��.�.N �.� .�mT.T.ry,TmmF.T� OFFICE USE ONLY This request void 18 months from validatlon date printed in this box.
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PLEASE PRINT OR TYP `
Date �^ Rou h-In ins ection
g p required7 � Yes No Inspectlon Other Than Rough-In: eady o❑ ill Call
��� �, You must call the inspector when r dy! Date Ready: � �G ���
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