P - 80949REQUEST FOR ELECTRICAL INSPECTION �*��
6 6 9=`* �� Minnesota State Board of Eleciriciry
1821 University Ave., Rm. 5-728, St. Paul, MN 55104
- Phone (672) 642-0800 �'��
Other:
"X" obove the woll: mvered by this request Enrer remarks in this space and on the ba<k of fh
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Calculafe Inspecfion Fee - This Inspectian Requesf will no� be occepfed without ihe correct fee:
Other Fee 8 Service Entrance Size Fee N CirwAs
Mabile Home Park Slall
Sfreef Ltp./TmNic Siq.
Boom
� Above 200_,
INSPECTOP'S USE ONIY
1 . 11
ihe elendmlinsmllmion descnbed herein on
Remod
copy
Fee
I THIS INSTALLATION MAY BE ORDERED DISCONNECTEU IF NOT COMPLETED WITHIN 18 MONTHS.
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I� I� III II III II II) II II�I I I II III � III I� OFFICE USE aNIY Thia reques vo�d 18 mon� volidetion do� nte � 60..
* 0 6 6 9 4 4 3 4* �g�a
- PLEASE PRINT OR TYPE
Reques� Dare RoigMn inspectim requiredg ❑ yex Na Inspection Ofher ihan RoogMn: ❑ Ready Na Will Call
�/�^ 9� �I'au musr mll tha inspeao. when reody� Dore Ready:
I, �] li<ensed contmcbr ❑ owner hereby requesf inspedion of the above elecfrical wark ot:
Job Address �Slreet, Box, or Raute No.) Ciy Zip Code
5. � J .vd . % 1 c�
Sxnm No. Township Nome « Na. Ranee No. Fire Na. C nN
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PowerSopplier
Elennml Contracior (Compo y N �
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hblling Address �Cmwcror or Ow�er Pedorminq I�s�allc
Phone No.
��a - y'�3�
Licenxe No. Nwster lic Nn (Plam E4
�i� - - --vV �53?' S��3/
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