P - 82352,
I'O 15—H26 � REQUEST FOR ELECTRICAL INSPECTION •'���
Minnesota State Board of Electricity F�
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 -__ _
(651) 642-0800 www.electricity.state.mn.us '� - `
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 on/y.
NSP SAYEFrS 3WITCti
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Fee - This Inspection Request will not be
ae # Service Entrance Size Fee
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
�ted without the correct fee.
# Circuits / Feeders
0 to 100 Amps
Above 100 Amps
TOTAL
�.�
� I hereb certi(y that I inspected the electrical installation described herein o� the dates stated:
Iffig8tl0� BOO Rough In Date
Special Inspection
Investigative Fee �� �at '�-- � C
THIS INSTALLATION MAY BE ORDERED DIS D IF NOT COMPLETED WITHIN 18 MONT!
..._ �...,_.� ..,�.u.......�.,..__:, :..,.......... . ._,. ._. ... ..... .. ...............°- --.°-°°---- - -:-• - - --.- . _ . . .. . validation date printed in this box.
I IIIIII (IIII IIIII (IIII IIIII III III� I�I � OFflCE USE WAY Th�s reQuest vad 1 S montbs from
* , o , 5 $ s � o � `�� ��" ���
a
PLEASE PRINT OR TYPE
Request Date Rough-In inspection requiredl ❑ Yes ❑ Inspection Other Than Rough-In: Ready Now O Will Call
4 rYfl111 You must call the inspector when ready! Date Ready:
�iAA�
I, [�Qicensed 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