P - 80865� REQUEST FOR ELECTRICAL INSPECTION
�� �- 5 91 Minnesota State Board of Electricity
1821 lJniversiry Ave., Rm. 5-128, St. Paul, MN 55104
Phane (612) 642-0�0 _ _
Farm � � .�V °'-"
Wa�er Hh. Lood Mpmt. Other:
reques�, tn�er remorks !n Pois space and on Me bock ol Poe whi�e copy
Cakulafe Inspection Fee - This lnspecfion Request will nof be accepted wifhout the correct ke:
Olher Fee It Service Entrance Size Fee N Circuifs/Feeders Fee
Mobile Home Park Stall 0 fo� 200 Amps 0 to 100 Amps
INSPECTOR'S USE ONLY
txe7-.�,z7 °/
thot I �nseecrtel the elecn�cd t�smllmion dexribed here�n
Investigative Fee �--'" � « �C
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITNIN 18 MONTHS.
OFFICE USE ONLY This request wid 1 B thxlrom wlidvlion date pr�nted In this 6ox_
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* � 5 3 2 5 9 1 5�K pLEASE PRINT OR TYPE ���
Ra9'+�'� �� - 2ough:n Inspection required7 Yes ❑ No Inspelno� Olher ll�an RougMn: ❑ Reody Now Will Call
(You must coll Ihe mspecar n eodyl Darz. Reody:
I, ❑ licensed conhacror owner hereby request inspecKon of fhe above electrical work at
lob Address �Shee1, 8wc, Rwle No.� Ciry Zip Code
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INSTNUCfiONS ON BACK OF YELLOW
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