P - 81170REQUEST FOR ELECTRICAL INSPECTION
0_Q C��_�� � � Minnesota State Board of Electricity =
�•+V 1821 University Avenue Suite S-128, Saint Paul. Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us
Home Duplex Apt. Bldg. 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.
NSP 3AVER'S SWITCH
Calculate lnspectic
�ther Installations
Mobile Home Park Stall
Street Ltg. ! Traffic Sig.
TransformerlGenerator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irrigation Boom
Fee - This lnspection Request wil! not be accepted without the correct fee.
�e # Service Entrance Size Fee # Circuits / Feeders
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amp:
INSPECTOR'S USE ONLY TO�
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I hereby certi that I ins ected the electrical installation described herein on the da1
Rough In Date
L_� urvasuyauve rCes I I ` I� L-'� 7"""' 1
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT GOMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY Ttrs request vad 18 rtwnths from validation date printed in this box.
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PLEASE PRINT OR TY
Requ�$t q@tg� Rough-In inspection requiredl � Yes � No Inspection Other Than Rough-In: � Ready Now ❑ Nldl CaN
���a�� You must call the inspector when readyl Date Ready:
I, ❑ licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
EB-OOOOtA-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY