P - 80833REQUEST FOR ELECTRICAL INSPECTION � °° .
�Q��/�7 a Minnesota State Board of Electricity
'UJ r' G� 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 -
�" (651) 642-0800 www.e/ectricity.state.mn.us :- `
Home Duplex Apt. Bldg. Other. New Addn
Commercial lndustrial Farm Remo Repair
Air Conditioner tg. 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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Calculate Inspection Fee - This Ins ection Request will 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. / Traffic Sig. Above 200 Amps Above 100 Amps
TransformedGenerator INSPECTOR'S USE ONLY TOTAL _D ��
Sign / Outline Ltg. Xfmr. �
Alarm/Remote Contro� .
Swimmino Pool
Rough In
installation described hereirt on the
Date
Investigative Fee � � C� - ��-2 =j —�% �
THIS INSTALLATION 1iAAY 8E ORDERED DISC ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
�T���. �TmTT.���mmT��TT.�mmT.�.�T�.�.OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rou h-In in5pection
g required? � Ye No Inspection Other Than Rough-In eady Now ❑ Will Call
You must call the inspector when r dy! Date Ready: j`
I,�icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
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Sedion No.l�ownship Name or No.
Occ ant '
%�t ��h a� ^�k �l�
Power Supplier
El�eirical Contractor / Com�any Name _
MaAin Address (Contractor, Company or Owner F
o� / G�l-o h <�
Authorized Sign�aturej (Contre or, Company or OW
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EB-00001A-12 5/1999 STA
Address
Contractor License No.
t�vi��v
ig Installation)
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Master Lic. No. (Plant
Phane
COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY