P - 82137REQUEST FOR ELECTRICAL INSPECTION
�.!_858_70(7 � Minnesota State Board of Electricity -
3 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.e�ectricity.state.mn.us :-•
Home Duplex Apt. Bldg. Other: change service from fuse to New Addn
Commercial Industrial Farm breakers Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elect. Heat Temp. Service
e tne work co is re uest, ter rem r �n t' s ace and on the back of the white co onl .
$� � 4 Inspec� oca p py y
Rot�rt Ciausan �
(651) 777-7885
Calculate Inspection Fee - This Inspection Reauest will not be accepted without the correct fee.
Jther Instaltations Fee # Service Entrance Size Fee # Circuits / Feeders I
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
TransformeNGenerator INSPECTOR'S USE ONLY TOTAI�,$1
Sign / Outline Ltg. Xfmr. �
AlarmJRemote Control
Swimming Pool
I hereby certiTy that I inspected the electrical installation described herein on the dates
Irrigation flough In Date
nvestigative Fee � � �-��j�;��V'�J
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED W HIN 18 MONTHS.
�� ' R� OFFICE USE ONLY This requesl vad 18 months from validation date printed in this box.
III�II �Ifll Illll �If�i ���1) Ili���� �I �1 • V'V ' ..J�-/
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PLEASE PRINT OR TVPE
Request Date pbu h-In ins ection r uired Yes � No In
g p eq spection Other Than Rough-In: � Ready Now �itl Call
41� 7� You must call the inspector w en readyl 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 II�STRUCTIONS ON BACK OF YELLOW COPY