P - 82361�
1_O � 5_829 � REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity F:-
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -_ _
(651) 642-0800 www.electricity.state.mn.us : •"
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remotl 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 on/y.
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimmina Pool
fV�P SAYER'S SWITCH
Fee - This Inspection Request will not be accepted without the correct fee.
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
0 to 100 Amps
Above 100
TOTAL
iA.Sa
described herein on 1he dates stated:
Investigative Fee F� � J��.--__ ��°� /2'a� I
THIS INSTA�A,JION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� � t.� .......................yt.`. ....:....,.'!�..f.�k'�;.�.� ..l.�.�...��.f�.J�:�'�J•..• � � � L';Ji'r:J.. . .... .. .. .. . .. ...
� IIIIII IIIII IIIII IIIII IIIII (II II� III� I�I OFFICE USE ONLY This requesl void 18 months tram validafion date printed in this box.
* 1 0 1 5 8 3* ��s� ���s�
PLEASE PRINT OR TYPE
Request Date Rough-In inspection required? ❑ Yes ❑ N� Inspection Other Than Rough-In: �Ready Now � Will Call
�.M ` e�y� You must call the inspector when ready! Date Ready:
I, [j(icensed 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