P - 80234/ REQUEST FOR ELECTRICAL INSPECTION �
�� � � � � � � � � 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 `��'"
the white copy only.
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Calculate Inspection Fee - This Inspection Requesi will not be accepted without the correc► lee:
Other fnstallations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Am�ps
Transformer/Generator INSPECTOR'S USE ONLY TOTP_�L
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mote Control
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the elechical installafion described herein on the da
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� � Investigative Fee — �"'ti �....�. ���f`�� I���� �_l,, G°
THIS INSTALLATION MAY BE ORDE�tED DISCONNECTED IF NOT COMPLETED WITHIN'�8 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinfed in fhis box.
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PLEASE PRINT OR TYPE
Req�est Daie � Rough-in inspection requiredZ ❑ Yes No Inspecfion Other Than Roughan: ❑ Ready Now Will Call
�3 t' U� You must call the inspectocwhen ready DateReady:
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
1ob Add ess (Sfreef, Box, or Route �lg.) � City Zip Co�de �
3 b " 5�' �� t`d� "s 3 2
Secfion No. � Township Name or No. Range No. Fire No. County �
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Power Suppli€r � � Addr
Electrical Contracror / Company Name
BWINE HTG. AiC & ELCCT. E::t
Mailing Ad 0 0� g�� Performing Insfallation)
or Ownac
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STATE BOARD COPY
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SEE INSTRUCTIONS ON BACK CiF YELLOW CUPY