P - 83134RE�UEST FOR ELECTRICAL ��rEC'TtON
t6-14 - 7 3 2� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN.55104 �
Phone(612)642-0800 ` '
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Con .�' Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. 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.
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Calculate Inspection Fee - This Inspection Request will not be accepted wi►hout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./TrafFic $ig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA SO
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the eleclrical insmllafion described herein on the dates sroted
Irriqation Boom Rouah-In Date
THIS INSTALLATION MAY BE ORDERED DISCO`N�CTED IF NOT COMPLETED WITHIN �'8 MONTHS.
OFFlCE USE ONLY This roquesf void 18 months from validation date printed in }his box.
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PLEASE PRINlT OR TYPE ���
Request Date Rough-in inspecfion required2 ❑ Yes No Inspection Olher Than Rough-In: Ready Now ❑ Will Call
�You must call the inspector when ready� Date Ready: �
I, �icensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
1ob Address (Sheef, Box, or Roufe No.� Cify � Zip Code
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Section No. Township Name or No Range No. Fire No. County
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Occupant f� Phone No. p�
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Mailing Address onhac or or ner P rforming Installafion�
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Authorized ' re �Conh r or ner PerForming i stallation)
EB-0 A-11 8/96 STATE BOARD C Y- SEE
�Plant Elect. Only�
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Pho e No. -
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C OF YELLOW COPY