P - 80903RE�UEST FOR ELECTRICAL INSPECTION ""`
4�q ��(i 0 Minnesota State Board ot Electricity
.1. 7 1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
� Home Duplex Apt. Bldg. Other: New Addn
Commerciol Industrial Farm Remod, Re air
Air Cond. Htg. Equip. Wafer Hfr. Load Mgmt. Other:
Dryer Range Elec. Heof Temp. Service
"X" above fhe work covered by rhis request. En�er remarks in this space and on Ihe back of rhe whi/e copy only.
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Calculate Inspection Fee - This lnspecfion Request will nof be accepted wifhout the mrrecl fee:
Other Fee N Service ntranc ' e Fee k Circuits/Feeders fee
Mobile Home Park Stall � 0 t 200 mps 0 to 100 Amps
Street Lip./Traffic Sia. Above 200_Amps Above 100�Amps
INSPECTOR'S USE ONIV
described herein on the daies smred
Imestigative Fee � i b—C
THIS INSTALLATION MAY BE OHDERED DIS ONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requav void I B months Fom wlidation dale prinled in this 6ox.
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Reqoes� DaM RougMn inspection requiredZ ❑ Yes ❑ Na Inzpecfion Oiher ihon RougMn: Ready Now 0 WIII Call
�You mun mll �he I�specror when reody� Dare Reody: 8//�
I, �censed confmc}or ❑ owner hereby requesf inspection of the obove elecfrical work at:
bb Address �Sneer, Box, or Rane No.� Ciy Zip Cade
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Seclion No. Township Name or No. Ronqe No. Fire No. Cw�
Occupan! Phone Na.
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Signo`yire�Conhaciw «
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BOARD COPV - SEE INSTHUCTIONS ON BACK OF YELLOW COPY
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