P - 81171� REQUEST FOR ELECTRICAL INSPECTION
'O`V�C7-323 9[] Minnesota State Board of Electricity -
� 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 _ _
(651) 642-0800 www.e/ectricity.state.mn.us
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Loatl 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 savER�s swrrcH
Calcu/ate Inspection Fee - This Inspection Request wil/ not be accepted without the conect fee.
Other Installations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TO�'
Sign / Outline Ltg. Xfmr. aQ,�
Alarm/Remote Control
Swimming Pool
I hereb certity that I ins ed the electrical installation described herein on the dates stated:
If�198t1011 BOO�I1 Rough In Date
Investigative ee r�'� � I"`�� �yd I
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
V W MwY.M_.��TM� T��M^ �A! rv.„��w���~.^�w�M.~�OFFICE USE ONLY This request vad 18 monihs trom validation daie printed in this box.
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PLEASE PRINT OR TY
Regugsj�tg,_ Rough-In inspection required? � Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now ❑ Will Call
� i����'� You must call the inspector when ready! Date Ready:
I, ❑ licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
E&00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY