P - 81273REQUEST FOR ELECTRICAL INSPECTION �.�"'�§,�.
7 J�- 5 7 6 Minnesota State eoard of Electricity
� 7821 Universiry Ave., Rm. 5-128, St. Paul, MN 55104
.. Phone (612) 642-0800 �`:�::�:�:
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"X" above the work covered by Ihis �equesG Enfer remarks in Ibis spoce ond on lhe back of the white copy only.
' I�Jase vn e�- }�ern �� l
Calcula�e lnspec/ion Fee - This Intpecfion Requesl will noi be occepfed withoW the mrrect ke:
Other Fee # Service Enhance Size Fee # Circuits/Feedere Fee
Mobile Home Pork Sfall 0 ro 200 Amps 0 to 100 Amps
Skeet Ltg./Traffic Sig. Above 200_Amps Above 100_Amps
Tronsformer/Genemtor INSPECTOR'S USE ONLY TOTAVj� `��
Slgn/Oufline Lty. Xfmr. J
Alarm/Remote Conhol
Swimminp Pool . . _ . .�
� Invesfigaiive Fee . � �...._. �""� �� •. 1✓N`'L��z �—_�
THIS INSTALLATION MAY BE ORFiERED DISC TEO IF NOT COMPI.ETED W�THW ie MONTHS
OFFlCE USE ONLY Thle requesf void I B momhs fiom validafian date prinled in ihis box.
I II� III II III (I I I II II) �II II I II III I IIII • r '�' �^ 3� 9�
s 0 7 5 6 5 7 6 5* a�J
PLEASE PRINT OR TYPE
Requesl qa^e � ^ gougMm IDspectton requiredd Yes No Inspaclion O�her Thon RougMn: eody Now O Will Call
j� 2, —�� �You man mll ihe Inspacmr when rEady� Da1e Ready:
I, �licensed confmcfor ❑ owner hereby requesl inspection of the above elecirical work ot:
lob Address IStreet Box, w RoWe Na.l , n ...i CiN.w ` 1 I ZIp Code
Sx�ion No. Township Nome or No.
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Power Supplier
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Eleurical Com
169�1 xylite
Moiling Addre�
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Authoriz¢b5iqnawre IConnacror or m
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Liceree Na.
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STATE 80AFD COPY - SEE INSTFUCTIONS ON BpCK OF YELLOW COPY