P - 81167REQUEST FOR ELECTRICAL INSPECTION
��_$CJQ'Q22 � Minnesota State Board of Electriciry - `�
V�+ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
' (651) 642-0800 www.electriciry.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.
N3P SAVER'S SWITCH
Calculate lnspection Fee - This lnsvection Reauest will not be acceoted without the correct fee.
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimminq Pool
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TO`�,��
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I hereby certi(y that I inspected the electrical installation described herein on �e dates stated:
Rough In Date
Investigative Fee Fl"a� �"_ I oataz � Z_ p 1 I
THIS INSTALLATION MAY BE ORDERED DISCONNECT'ED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR
Requg� L]atp _ Rough-In inspection required? � Yes � No Inspection Other Than Rough-In: ❑ Ready Now ❑�II 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:
EB-OOOOtA-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY