P - 82040�
� REQUEST FOR ELECTRICAL INSPECTION �
� ° � � � � � � (� � Minnesota State Board of'�Electricity � � �
J 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 = e
(651) 642-OS00 www.electricity.state.mn.us '��'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Hig. Equip. Water Htr. Load Mgmt. Other.
Dryer Range Elec. Heaf Temp. Service
"X" above tl�e work covered by this request. Enter remarks in fhis space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will no► be accepted wiihout fhe correci fee:
Other Installations Fee # Service Entrance Size Fee # Circuifs / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 2 0 to 100 Amps
Street Ltg. / TrafFic Sig. Above 200 Am s Above 100 Amps
Transformer/Generotor INSPECTOR'S USE ONLY TOTAL �
Sign / Outline Ltg. Xfmr. �O S
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the electrical installation described herein on the dates stated:
�ffl94flOf1 BOOfII � Rough-In . .. � Date
Special Inspect
� Final Dat -
Investigative Fee `
THIS INSTALLATION MAY BE ORDERED DISCONNEC7ED IF NOT COMPLETED WITHIN 18 MONTHS.
�_ � OFFICE USE ONLY This request void 18 months from validation dafe prinfed in fhis box.
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PLEASE PRINT OR TYPE
Request Dafe Rough-in inspecfion required? ❑ Yes ,*lo Inspection Other Than Rough-In: Ready Now 0 Will Call
�i ���Q � You must call the inspecfor when ready Date Ready:
I,'� licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreef, Box, or Roufe No.) � City � Zip Code
��O — �i'� l� ST. XE Fr,a✓�e
Section No. Township Name or No. Range No. Fire No. County
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Occupanf Phone No.
„�a�na (2ec�Pc�eH
Power Supplier Address
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Elechical Contracror / Company Name - Contracfor license No. Master Lic. No. (Wani Elect. Only�
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Mailing Address (Contractor, Company or Owner Performing Insfallafion�
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Aufhorized Signafure �Confractor, Company or Owner Performing Insfalla 01 Phone Number
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EB-00001A-12 5/1999 STATE RD PY SEE INSTRUCTIONS ON BACK OF YELLOW COPY