P - 80840REQUEST FOR ELECTRICAL INSPECTION �
���� � O� Q � Minnesota State Board of Electricity
-° 0 �� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 " '
Home Du lex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. 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 Inspechon Fee - Th�s Ins tio equest w�ll not be accep►ed without 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 Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT//�n1,�
Sign/Outline Ltg. Xfmr. <�(J �
Alarm/Remote Confrol
Swimming Pool
I hereb certi that I ins the elechical insMllafion deuribed herein on the dales stated
IrrigaFion B RougMn Dare
Special Insp
Final ��y- L �../`
Investigative fee �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 monfhs from validation dafe prinfed in fhis box.
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PLEASE PRINT OR TYPE
Request Da �� � Rough-in inspecfion required? ❑ Yes o InspecKon Other Than Rough-In: ❑ Ready Now Will Coll .
�You musf call the inspeclor when ready) Dafe Ready:
I, (icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Add Street, Box, w R ute No.) Ciy Zip Code
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Secfion No. Township ame or No. Range No. Fire No. Coun ��� �
Oaupant / � Phone No.
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Power $upplier � Address� `�� ��� ��
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Elec ' a n c �Com n ame) � Con ctor license No. Masfer Lic. No. (Planf Elecf. Onl�
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Mailing Address�k r of Own �� ing Instal�afion) �
/ �� �
Authori Si atur onhactor or g Insfallation� �e .'/���
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EB-00 A-11 8/96 � ARD COPY - SEE INS'ffiUCTIONS O CK OF YELLOW COPY