P - 80853a��-413 �
"X" above fhe work covered by this
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Calculafe Inspecfion Fee - This In�
Other Fee
Mobile Home Park Stall
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REQUEST FOR ELECTRICAL INSPECTION
Minnesota Sta[e Board of Electricity
1827 Universiry Ave., Rm. 5-128, St. Paul, MN 55104
Phone (612) 642-0800
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� Elec. Heat � � Temp. Service �
reques�. Enfer remarks in fhis spoce and on Yhe back of the white copy only.
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�c/ion Request will nof be occepted wifhaut �he correc� fee:
# Service Entrance Size Fee # , Circuits/Feeders Fee
0 ro 00 Amps 0 to 100 Amps
Ah��a �nn Amns Above 100—_ —Amos
INSPECTOH'S lISE ONLV
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dmes smiad
Investigafive Fee � Z � �`" "-
THIS INSTALLATION MAY BE ORDERED DISCONNEC7ED IF NOT COMPLET D WITHIN 18 MON'fHS.
OFFILE USE ONLY This requeslwid I B months hom validation date primed in this box.
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* 0 7 6 0 4 1 3 5* �5y 7
P SE PRINT OR TYPE
Request Date Roi.gh�in inspecnon �aqobedx ❑ y¢s No Inspeclion O�her Than Rough-In-. ❑ Ready Now ill CaA
�-�/� 99 (YOO m�n mll ihe ��specm, whan readyl Dare Ready
I, �censed confmctor ❑ owner hereby requesf inspection of ihe above electrical work at:
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Sec�ion No. iownship Name or Na. Range Na Fire No. Co L
Occopanr � Phone Na.
Power Supplier Addrus
Elechiml Can r C � Conhanw License No.
17928 82nd PL, NO. C' f} n i S 9.
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STATE BOA COPY - SEE INSTBUCIIONS ON BACK OF YELLOW CGPY