P - 81277� RE�UEST FOR ELECTRICAL INSPECTION �`�"�
_� �. O� p�^ . Minnesota State Board of Electricity
O O � 1827 Universiry Ave., Rm. 5-128, St. Paul, MN 55104
Phone (612) 642-0800 _1 N 99zlR[L7 .,��-
Farm
Dryer Range Elea Hea} Temp. Service
"X" obove the work <ove�ed by this requesL Enter remarks in fhis space ant� on the back of Ihe w6ife copy only.
C�lAAX+E SERUlCFTp ZOOA. DA�EL J��Ew
6vP.esS P'tersr� S��Er,
Calculafe Inspecfion Fee - This Inspection Requesf will nof be accep�ed wifhout fhe correcf 7ee:
Other Fee # Service Entrance ' e Fee # Circui[s/Feeders Fee
Mobile Home Park Slall 0 to 200 Amps Z, 0 l0 100 Amps
Sireet Ltg./TmHic Sig. Above 200_Am s Above 100_Amps
Tmnskrmer/Generalor INSVECTON'S USE ONLY TOTAL �
Sisan/Oudine Llq. Xfmr. ZS` S
ihm I�nxoecied �he elxrckal msrallanon desn�bed herein on fhe
invesugarrve r - � ✓ '.]
THIS INSTALLATION A ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This reqoeslmid 18 monihs from validafion date prinled in �his bo..
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PLEASE PRINT OR TYPE
Requex� Dote Raughin inspMion required? ❑ Yes � No Inspeciion OiM� ihon Roo h-In: ❑ 2eady Naw ill Call
� 3O �You muircollihe inspxior when ready� Da�e Ready: �
I, �licensed confmctor ❑ owner hereby requesi inspecfion of fhe above elecirical work al:
Job Addrexs (S��eel, Bo:, or Rawe No.) Ciy Zlp Code
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s�ro� No. row�:hro Na� o, No. x���a n�„ F��.� ��.. �..,,_..
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SiATE 60ARD C07Y - SEE INSTRUCTIONS
Lirense
No.