P - 82358�. � i =01 �-s31 �
REQUEST FOR ELECTRICAL WSPECTION -
Minnesota State Board of Electriciry F- �
1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 --- -
(651) 642-0800 www.e/ectriciry.state.mn.us : '
Home Duplex Apt. Bldg. Other: New Addn
Commercial Intlustrial 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.
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Ca/cu/ate Inspection Fee - This Inspection Reauest will not be accented without the correct fee.
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irrigation Boom � �} n
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
0 to 100 Amps
Above 100 Amps
TOTAL
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I herebvi certiN that I insoected the electrical installation described herein on the dates stated:
Investigative Fee F� � I�e� ?J o' 6� I
THIS tNSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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I I I I IIII II IIIII �I I� OFFICE USE ONLY This reque& void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-In inspection required7 ❑ Yes � N6` Inspection Other Than Rough-In: r7Ready Now ❑ Will Call
�_� �,�M 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 5/7999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY