P - 77864" REQUEST FOR ELECTRICAL INSPECTION ,�.p EB-00001-03
IN4�307 � .
' See instructions for completing this form on back of yellow copy.
","X"" Below Work Cov�red by'This Request
Add Rep. Type of Building Appliances Wired Equipment Wired
x' Home Range Temporary Service
Duplex Water Heater Lightiny Fixtures
Apt. Buiiding Dryer Electric Heatin
Commercial Bldg. Furnace Silo Unloader
Industrial Bldg. Air Conditioner Bulk Milk Tank
Farm Other Pecify OtherlSUecifyl
t er Specify Ot er Other
ite lnspecUon Fee Below
Fee ServiceEntranceSize
�to100Am s
� 101 to 200 Amps
Above 200 Amp�
Transformers
Si gns
in
Final
This request void
18 months from
Thfs request void
78 months from
Fee Feeders�Subfeeders #
Oto30Am s
31 to 100 Amps
Above 100_Amps
Remote Control Circ.
Special Inspection S
�a � �
,-� �'� � � �
�iteq�est Date Fire No.
�-�,� ��
� Licensed Elecirical Contractor
❑ Owner
uate
Date
�,_„ 14
Fee Circuits
0 to 30 Am �
3•S a 31 to 100 Arr
Above 100_
i Partia{�'Other
� TOTAL FEE
I, the Electrical
Inspector, hereby
certify that the above
inspection has been
made.
. U
��� � ��� �
Rough-in Inspection
Required? �Ready Now � Will Notify, Inspec-
�Yes ❑ No tor When Ready
1 hereby request inspection of above
electrical work installed at:
MINNESOTA STATE BOARD OF ELECTRICITY 7HIS INSPECTION REQUEST WILL NOT
Griggs-Midway Bldg. — Room N•191 BE ACCEPTED BY THE STATE BOARD
7821 University Ave., St. Paul, MN 55104 UNLESS PROPER INSPECTION FEE IS
Phone (812► 297-2111 ENCIOSED.