P - 823391'� 1�_G52 � REQUEST FOR ELECTRICAL INSPECTION E
V Minnesota State Board of Electricity F:-
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 -- -�
(651) 642-0800 www.electricity.state.mn.us
'X" above the work covered by this request. Eht remarks in this space and on the back of the white copy on/y.
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Calculate Inspectic
�ther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Fee - This Inspection Request will not be
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
Rough In
� � Investigative Fee � � I
THIS INSTALLATION MAY BE ORDERED
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IIIIIN ��`. �. �iI IIII) llll llll� �_ T_
���
*�o s 5*
ao,.���f iin�e _
without the correct fee.
Circuits / Feeders Fee
0 to 100 Amps
Above 100 Amps
TOTA��►}�
Jv
Date
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�NNECTED IF NOT COMPLETED WITHIN 18 MONTI
. x • •_•�.- .�.�.�,�. � �. �.� ... . ... ... ....................... . .
iNLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
.r. �. . . �. . , .
electrical work at:
EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY