P - 80907675-741 �
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REQUEST FOR ELECTRICAL WSPECTION `�"�'" `
Minnesota State Board of Electricity
1827 Universiry Ave., Rm. 5-128, 5t. Paul, MN 55104
Phone (612) 642-0800 �.�
Apl. ISltlg. Vmer: �q„/` `u...
farm {�eu�.. �C��'
Woler Hfr. Load Mgmt. Other:
Elec. Heal Temp. Service
reques�. Enter iemarks in this space and on
ICalculafe Inspecfion Fee - 7his Inspec/ion Requesf will nof be accepted wifbou/ fhe correcf fee:
Other Fee # Service Ertrance Size Fee # Circuits
Mo6�Park Stal� n 0 to 200 Amos ��� 0 to 100 A
INSPECTOq'S USE ONLY
g. Xfmr.
Control
800m
Do{e
copy only.
Fee
llnvestigafive Fee — — '' � —C �J � "��
THIS INSTALLAT�ON MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE U8E ONLY This request wid 18 monfhs from volidarb� dme printed ia lhis box.
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PLEASE PRINT OR TYPE
4YeSt re uo�gn.m ��,�nm� �eym�edz re> ❑ No i���ro� an�, rho� ao�yn��: ❑ aeady Na w�u can
$ �- � lYou musr mll the ��spe�ror whe� r � Dore Reody:
' ensed contmc�or ❑ owner hereby requesf inspection of the obove electrical work ot
o Addrea �S�reet, Box, w Roole No.) Ciy Zi Code
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SfATEBOARDCOVY-SEEINSTRUCT10N5
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