P - 82343�'O1 5—H23 a REQUEST FOR ELECTRICAL INSPECTION E
Minnesota State Board of Electricity `�
1821 Universiry Avenue Suite S-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 Contlitioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elect. Heat Temp. Service
X" above the work covered 6y this request. Enier remarks in this space and on the back of the white copy on/y.
Calculate
Mobile Horrie Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remo4e Control
wsa savEa� swiTCr+
Fee - This Inspection Request will not be
�e # Service Entrance Size Fee
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
I herebvi certiN that I
In
�cepted without the correct fee.
# Circuits / Feeders I
0 to 100 Amps
Above 100 Amps
TOTAL
�.�
.
installation described herein on the dates
Invesiigative Fee �"� � �� 26-�/ , I
THIS INSTALLATION MAY BE ORDERED DISL� NECTED IF NOT COMPLETED WITHIN 1� MONTHS.
yr...f�.,..._..c.u.v.�._...r_..,.._._u.rm•_3ua:!_._,_._�r_._.....y.� j._...,_.__.._.._�...�.__.•_.._3'_...�.___.......1,....y.� ....:...................... ........_.. -
I II I(Iltl IIIII I II I(II� I I II) OFFlCE USE ONLY Triis requeat vad 18 months from validation date pnnted in this box. J
III I I IIIIIIII �II QIJ "� �
a �- 5s�
*10158 6*
PLEASE PRINT OR TYPE
Request Date Rough-In inspection required? ❑ Yes ❑ NO` Inspection Other Than Rough-In: CTReady Now ❑ Will Call
�� d�� You must call the inspector when readyl Date Ready:
I, [�icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY