P - 81410REQUEST FOR ELECTRICAL INSPECTION
5 8 7���� Minnesota State Board of Electriciry �
1827 Universiry Ave., Rm. S-126, St. Paul, MfJ 55104
. Phone (612) 642-0800 a
��v fhe work covered �this reques�. Enter remarks in �his spoce and on tlre back of tlie whi�e copy onfy.
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Cakula�e Intpec�ion Fee - This Inspeclion Request will not be a<cepted wiMouf fhe rorcec� fee:
Other Fee # Service Entrance Size Fee # Circuits
Mo6ile Home Park Stall � 0 to 200 Amps 0 to 100 A
Streel Ltg./TraHic Sig. Above 200 Am s A6ove 100
TransformerlGenemSOr N15PECTOR'S USE ONLY
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 78 MONTHS.
OFFlCE USE ONLY This request wid 1��hs fr«n validafion dak primed in �hls bon.
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* � 5 8 7 2 1 5 5 s PLEASE PRINT OR TYPE
Re oesf Date Ragh.n irepecnon required2 ❑ Ye3 o I�pedion O�her ilwn RougMa ❑ Ready Now ill Call
�! �'�� � �You m�st m1i �he Inspec�or when reody� Dare Ready:
I, icensed wnhactor Q owner hereby request inspection of ihe above elecirical work ot:
Job Address �Sheeq emc, or Rwie Ciy Zip Code
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COPV - SEE INSTIiUCM/NS ON BAGK
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