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Home Dupler
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Air Cond. Hfg. Ei
I Cakulale
Mobile Home
Sfreet Ltp./Trc
Farm
requesf.
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1827 University Ave., Rm. S428, SL Paul, MN 55104 �
Phone (612) 64�0�(Ij�
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Service Q% //1S �
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in this space and on fhe back oi fhe white copy
Fee - This Inspection Reques� will nof be accepted wifhout the correct fee:
Fee N Se�'�ce Entrance Size Pee # Cirtuits
rk Stall 0 to 200 Amps ���
Sig. Above 200_Amps Above 100
i¢ldb� INSPECTOH'S USE ONLY
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Invesligofive Fee
THIS INSTALLAT N M Y BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
` OFFlCE USE ONL� This reqi:ersl void 18 monlhs hom wlidation dare p�inted in �his 6ox.
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* 0 5 3 2.5 9 6 4* PLEASE PRINT OR TYPE
Req�e,r poro �� /� � gough�n inspento� required? Yes No I�spection ql�er Tho� RougM�- ❑ Ready Now Will Call
S �You musrcallthe i�specmrwh n reody) Dote Reody:
I, ❑ licensed contraclor owner hereby request �inspection of the above elechical work o�:
Jab Address (Streai, Ba:, or kaure No.j Cly Zip Code
/30 7/�c �/Z r�J� �-r�ol/ SS{3�
Sxlion No. Township Na�ne or No. Ronge No fire No. Cwny
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Elech;ml Canhacror (Compo�y Name�
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Nwilino Address Konnaaar ar Owner Paiormina in
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Conim<t« Gcense No. Mos�er Lk. Na (Plonr EI
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