P - 80358C�=92�-?58 �
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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 " '
"X" above the work covered by ihis request. Enter remarks in this space and
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copy only.
Calculate Inspection Fee - This Inspecfion Req t will not be accepted wifhout the correct fee:
Other Insfallafions Fee # Service Entrance Size Fee # Circuits / Feeders Fce
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
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ecfed the electrical installatic
Irrigation Bo ►�� Rough-In
stated:
Investigative Fee Fir�ol �� I Du� ��,� ��C I
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THIS INSTALLATION MAY BE ORDERED DISC CTED IF NOT COMPLETED WITHI 18 MONTHS.
_ OFFICE USE ONLY This request void 18 monlhs 6om validation date printed in this box.
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PLEASE PRINT OR TYPE
1, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo Add ss (Street, Box, or Route No.) City__,�� ` Zip Code
D � �- �.�
$ecfion No. Township Nam���Fi�; No. Ran e No. Fire No. County � �
Occupanf
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Power Supplier � ^
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E��`��`IV`���BL����LEC?RIC. INC.
M����oDn e�tapids ��M �5433 �f
Aufhorized Signature (Contrac mpany or Owne
EB-00001A-12 5/1999 STATE B 7
Phone No.
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY