P - 81336RE�UEST FOR ELECTRICAL INSPECTION �
7��' C (] Minnesota State Boartl of Eled�iciry �j
� J� J � 1821 Univereity Ave., Rm. &128, St Paul, MN 55104 �'
Phone (612) 642-0800 �'�
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Ronge Elec. Heat Temp. Service
X" work covered by �hi5 �equest ENer remarks in ihis spoce a�d on the bock of the whi�e copy only.
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Calculafe Inspecfion Fee - This Inspection Requesf will nol 6e accepted without �he mrrecf fee;
Other Fee # Service Entranc ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 0 Amps 0 fo 100 Amps
Sheet Llq./Troffic Siq. Above 200_Amps Q Above 100_Amps
INSVECTOP'S USE ONLY
ine Llg. Xfmr.
mote Contwl
� Pool
Boom '
spection
ve Fee
a� me aa��
�„TkU$JNSTALLATION MAY_BE ORDERED DISCONNECTED IF NOT CObIPLETED WITHIN 18 MONTMS._
OFFICE USE ONLY ihis reqoest wid I 8 momhs hom volidafion date printed in �his 6oz.
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* 0 7 3 U 5 3 9 4* j�s
� PLEASE PRINT OR TYPE
Reques Rough.n irepecnon reqolred? ❑ Yes o Inspedion Oiher Thon RwghAn' Reody Now 0 Will Call
�� Q (You moa mll fie'mrpenor when reody� Dme Reody:
I, �1'`ensed contractor � owner hereby request inspecfion of the a6ove eleclrical work aY.
Jo6 Addmss �Sneeq Bo., or Raure No.l Ciry Zip Cade
�.? � ��z, s � ra��
Safion No. iownship Name or No. Ronpe No. Fire No. Caunty
or Vwner �ertorming insioimtion7
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pF YELtOW COPY �