P - 81606r
�' �j % �j REGlUEST FOR ELECTRICAL INSPECTION �.HE
—O � "' ` �" � Minnesota State Board of Electricity —
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 - -
(651) 642-0800 www.electricity.state.mn.us . `�
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. '" Load Mgmt. Other:
Dryer Range Elect. Heat Temp. Service
'X" above the work covered by this request. Enter remarks in this space and on the back of the white copy on/y.
Calcu/ate
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimmina Pool
i'v�i�` �:r��'4r"��i��';� �:xvi`i M�i_i {i'v�"i�1...L.A�1iE.iiv
Fee - This Inspection Request will not be
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
1NSPECTOR'S USE ONLY TOTAL
2C1..'�r0
I herebvi certi(v that I inspeded the electrical installation described herein on the dates stated
Date
Final ' D eZ }.2 '7 . �
MAY. BE QRDERED NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
�E �SE ONLV rnis r"eques{ryoicJ i6 monihs from valida n dat p inted in this 6o�y�
IIIIIIIII I�I�IIII�� III�IIII IIIII�IIIII
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* 1 0 1 6 7 8* � �Z°� ����I���t �no�[lqC�
PLEASE PRINT OR TYPE
Re uest Date
�����t �� f?ough-In inspection required? � Yes p No Inspection Other Than Rough-I : � Read Now�[] Will Call
You must rall the inspector when ready! Date Ready: ��/�Q(�(�
I, d�icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
EB-00001A-12 5/1g99 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPV