P - 82568REQUEST FOR ELECTRICAL INSPECTION �` ��E`
�—O ��—��O � Minnesota State Board of Electricity ���- 3
- 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 >= _. --
(651) 642-0800 www.electricity.state.mn.us `�z��:
v 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 whlte copy onry.
Calculate
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
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fVSP SAVER'� �WITCH
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n Fee - This Inspection Request will not be accepted without the conect fee.
Fee # Service Entrance Size Fee # Circuits / Feeders
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL
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I hereby certify that I inspected the electrical installation described herein on the date
Rough In •Date
Final u te
�vestigative Fee �g' —C�� �1
THIS INSTALLATION MAY BE ORDERED DIS NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
FFICE USE ONLY This request void .18 months from validation �date�printed in this box.
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PLEASF PRINT (1R TVPF
Request Date Rough-In inspection required? ❑ Yes ❑ N6� Inspection Other Than Rough-In: � Ready Now ❑ Will Call
You must call the inspector when ready! Date Ready:
I, OQicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
EB-00001A-12 S/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY