P - 81280REQUEST FOR ELECTRICAL INSPECTION •�
����� r� r] Minnesota State Board of Electricity
G L 1821 Universiry Ave., Rm. 5-128, St. Paul, MN 55104
Phone (612) 642-0800 �:
Home Duplex Ap}. Bldp. Ofher: New Addn
Dryer Range Elec. Heaf Temp. Service
"X" above the wark covered by fhis requesL Enter remorks in lhis spoce and on the back of the whife copy
�CS'`�--
Colculaie Inspection Fee - This Inspecfion Reques/ will no� be occepfed withou� the mrrect fee:
O[her Fee # Service Enhance Size Fee ri Circuifs/Feeders FeR
Mobile Home Park Stall 0 to 200 Amps / 0 to 100 Amps
StreetLtg.fTwffic5ig. Above200—Amos Abovel(�_Amps
Transformer/Genembr INSPECTOR'S USE ONLY TOTAL ��.
Dare
. THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 78 MONTHS. I
OFFICE USE ONLY ihis requesrwid 1 B mon�hs 6om wlidotion daie primed in this box.
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* 0 6 4 6 9 2 2 5* �j%7
PLEASE PRINT OR TYPE
Reqoen Dare RougMin inxpeciion reqoired? ❑ Yes Inspeciion Oiher Than Rough�lm dy Now � Will Call
�Yoo mos� coll ihe inspecmr when ready) Daie Ready:
I, �licensed contmctor ❑ owner hereby request inspection of fhe obove eleciricol work af:
o. ua-O
�
,V
License No.
17��
illing Address �Conhacror or Owner PnForming Ins�olL
2iia w�,s�.t�a�:oK s� N.e.
� � �st-62oo
COPY - SEE INSTRUCTIONS ON BACK OF YELLOM� COPY �