P - 812765�2 572
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REQUEST FOR ELECTHICAL INSPECTION
Minnesota State Board of Electricity
1821 Universiry Ave., Rm. 5-128, St. Paul, MN 55104
Phone (612) 642-0800
. Other: �, � New
Farm Ra�,r
Water Htr.
Elec. Heat
requesl. En�er
Service �
in �his space ond on
coPY
N'
Calcula�e Inspecfion Fee - This Inspecfion Reques� will not be accepfed without the correct Fee:
Olher Fee S Servire En[rance Size Fee # CircuiWFeedere Fee
Mobile Home Pork Stall 0 to 200 Amps % 0 to 100 Amps ; E
Street Ltg./Tmffic Sig. Above 200_Amps Above 100—Amps
Transformer/Genewror � inscecron•s use orv�v TOTAL��r/-7�
Sign/Oudine Ltg. Xfmr. �v
Alarm/Remote Control
Swimming Pool i hereb csni �hm I ins ie8 ihe elecviwl in mllanon deur'6e Mre�n o� �he dores sbied
�RI9Ofl0(1 BOORI Roi�IJ� . . . �Day-^ _ �/ C^!
I THIS INSTALLAiION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. _L
OFFlCE USE ONLY This request void 18 monllis hom volidofion doie prinrxd in �his boa.
Il���������l�n�ll��l� ���� ��I�����I� � �s
* � 5 3 2 5 7�L .i 7t PLEASE PRINT OR TYPE
Requeu Dye Roughin inspeciion raquiradx �y� ❑ No �nspecnon O�her Thon RougMn: ❑ Reody Now � WII Call
���/�'f �Vou must call �he lospecror when ready� Date Ready:
I, ❑ Iicensed conhacbf �owner hereby requesf inspectian of the above elxlricol work ot:
Job Address �SVaet, Bw, or Rook No.� Ciy Lp Cade
13�0 6y v-2 Fr: � Ic 5'S</3 -z
Section No- Tom�ship Name or No. Ronge No. Fire No. oonN n
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�er5upplier Addr
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vtml Conkaclur �Campony Name�
0t„r.�.��
Il�g Address (Commc�or w Owner Perl«ming Insmllotion�
S�n. P ,
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w w Owner ehor ng Insmllafion� PI
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STATE BOMD COPY - SEE INSTAUCT70NS ON BACK OF YELLOW COPY
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