P - 80229REQUEST FOR ELECTRICAL INSPECTION
O_QFQ_QQ/{ � Minnesota State Board of Electricity F:- -
vvv vv-r 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
4 (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. Load Mgmt. Other:
Dryer Range Elect. Heat Temp. Service
'X" above the work covered by this request Enter �n this space and on the back of the white copy on/y.
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Caicuiate Ins ection Fee - This Inspection Request wi/l not be accepted without the correct 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. i Traffic Sig. Above 200 Amps Above 100 Amps
TransformedGenerator INSPECTOR'S USE ONLY TOTAL � �
Sign / Outline Ltg. Xfmr. JN�d g-�r-`� p�
Afarm/Remote Control
Swimming Po I
Iffl BtlOtl BO I hereby certi(y that I inspected the electrical installation described herein on Me dates stated:
9 Rough In Date
Special Inspection
Investigative Fee Finai Da�a,,3� �
THIS INSTAL�ATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This request void 18 months from vatidaiion date printed in this box� �mm�
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*08588345*
PLEASE PRINT OR TYPE
Reque Da(g Rough-In inspection required? ❑ Ye o Inspection Other Than Rough- : ady NowO fll Call
You must call the inspector when ready! Date Ready:
I,`�licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
EB-00001A-12 5/1999
STATE BOARD COPY
SEE INSTRUCTIONS ON BACK OF YELLOW COPY