P - 84213�
REQUEST FOR ELECTRICAL INSPECTION �
�J li �- 6 0 6 Minnesota State Board of Electricity
1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800
ome Duplex Apt. Bldg. Other: New ddn
Commercial Industriol Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other.
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the,white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accep►ed without fhe correci fee: `
Other Fee # Service Entrance Size Fee # Circuits/Feeders Pee
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 oN�v ' TOTA �
Sign/Outline Ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins ted fhe elechical insMllaKon described herein on the dafes stated
irrigation Boom Rough-In Date
Special lnspectio
Final - � Dare �/
Investigative Fee ,��- � 2 6- / r3
THIS INSTALLATION MAY BE ORDERED DIS NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 monfhs from validallon dafe prinTed in this box.
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I I�II II ��I (I �II I) �I) II �II � II (� II� I� �II I IIII ; 3� 3
* � 5 � 3 6 0 6 6* PLEASE PRINT OR TYPE '
Request Date Rough-in inspection required? ❑ Yes o Inspection Olher Than RougMn: ❑ Ready Now ❑ Wili Call
� l� � �You must call ihe inspeclor when ready� Daie Ready: � ��
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Add/ress �Sheet, Box, or Roufe No-.$) 6 /� '! City � Zip rCode ^�
1(f � . �� � .'T +r Ly� !i' � � � � Y "� � � � �J+� I�
Section No. Township Name or No. Range No. Fire No. County �
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Occupanf Phone No. -`� `-
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Power Supplier Address � �.
Elechi�cal Co;hacfor �Compan Name) �_ � Conhqcf � License No. Master Lic. No. �Planf Elect. Only�
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Ma" dress (Conh cfor or er Pe rming Installafi � �r-
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Authorized Sign re � onhador or Owner Performi Insfallafion) Phone� No.
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EB-00001 A-I 1 8/9 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY