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requesf.
REQUEST FOR ELECTRICAL INSPECTION ��,
Minnesota State Board oi Electricity
1821 Universiy Ave., Rm. 5-128. SL Paul, MN 55104
Phone (612) 642-0800 -
space and on the bock of Me whire copy
P�csb (�.� D�1.�-`�"Y� (D�l= L"17—? 8 �S
Calculafe Inspecfion Fee - 7his Inspedion Requesf wil! nof be accep�ed withouf lhe rorrecf fee:
Other Fee # Service Entrance Size Pee N Circuits/Feeders Fee
Mobile Home Park Sfall 0 ro 200 Amps 0 to 100 Amps
Streel Ltg./Traffic Sig. Above 200_Amps Above 100_Amps
Tmnsformer/Genemfor INSPECTOF'SUSEONLY TOTAL�,t�
�,� �.
Siqn/Oulline Liq. Xfmr. � }7�
elennml I�:mllmon described herein on the dales
800m
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTKS._ J_
OFFIGE USE ONLY This request wid 18 months from volidanon da�e printed In fhis 6ox.
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PLEASE PRINT OR TYPE
Requesr C � Rough�in Inspection required2 ❑ Yes No I�specfian Other Than Na�yh-Im ❑ Ready No , III Call
/l �J✓ (Yoo musi call the mspedor when reodyl Dore Ready:
I, � licen:ed coNmcror � owner hereby reques� inspeclian of the above elecVicai work at:
Job Addrese ISneep 8w, or Roote No.� Ciy _ �� Zip Cade
or
Pho�e Na.
�Iln �
naa,e,.
. ConvaCOr License No. Mc
IE. N.E.
9 m,muaro��
�r Performins Insmllation� Phc
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'E BOARD COPY - SEE INSTflUCTIONS ON BACK OF YELLOW COPY