P - 81177E
REQUEST FOR ELECTRICAL INSPECTION
�'C�SC.�-331 � Minnesota State Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
� (651) 642-0800 www.e/ectriciry.state.mn.us . �
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remotl 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 whlte copy orny.
NsR savER�s swrrcH
Calculate Inspectic
�ther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
TransformeNGenerator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irrigation Boom �� � �
Special Inspection
Fee - This Inspection Request will not be accepted without the correct
:e # Service Entrance Size Fee # Circuits / Feeders
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 A
INSPECTOR'S USE ONLY TO�
I herebv certiN that I insoected the electrical installation described herein on V
Rough In
Date
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Investigative Fee � —
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
' ._.�.._ T.. ,r.�.._.,.... t t._.._.T,..�_,� �_..... T.,�....�...,...��CE USE ONLY This request void 18 rtwnths from validadon date printed in this box.
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PLEASE PRINT OR
Requ�sZj�t�_ Rough-In inspection required? ❑ Yes ❑ No Inspection Ofher Than Rough-In: � Ready Now ��II Call
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You must call the inspector when ready! Date Ready:
I, ❑ licensed 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