P - 825691 M014-551 �4 B :E
REQUEST FOR ELECTRICAL INSPECTION ��°°
Minnesota State Board of Electricity `F ..-_ �-
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 �`�' _.
� . 651 642-0800 www.electrici state.mn.us �yyi��
� ) tY• ��._ ��
v Home Duplex Apt. Bitlg. 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 only.
Calculate Insoection Fee - This
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
h1SP SAVER'� �WITCH
will not be
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
� " .t �V V
�ted without the correct fee.
# Circuits / Feeders
0 to 100 Amps
Above 100 Amos
TOTAL
�.�
I hereby certify that I inspected the electrical installation described herein on the dates stated:
Irrigation Boom Rough In Date
Special Inspection
Investigative Fee Final Dat _ � `G�
I . THIS INSTALLATION.MAY BE _ORDERED DISCONNECTED.IF.NOT COMPLETED WITHIN 18 MONTHS.
I IIIIII IIIII IIIII IIIII IIIII III IIIII IIII IIII OFFICE USE ONLY This request void 18 months from validation date printed in this box.
* 1 0 7 4 5 4* r�"�^� � �•J�
���� �j
PLEASE PRINT OR TYPE ���`-'
Request Date Rough-In inspection required? ❑ Yes ❑ N5 Inspection Other Than Rough-In: L� Ready Now ❑ Will Call
,� �� p�� You must call the inspector when ready! Date Ready:
I, [j�icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
EB-0OOO1A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY