P - 81263REQUEST FOR ELECTRICAL INSPECTION
7�ry� n C r� Minnesota State Board of Electricity
�: a..� L 1821 Universiry Ave., Rm. 5-128, St. Paul, MN 55104 ��
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"X" obove fhe work covered by fhis requesG Enler remarks in �his space antl on lhe back o� iYie whde copy omy.
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Colculaie Inspection Fee - This Inspection Requesl will not be accepted wifhou� the mrrect fee:
Other Pee 8 Service E�trance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 ro 200 Amps 0 to 100 Amps
Sfreet Ltg./Tmffic Sig. Above 200_Amps Above 100_Amps
Transformer/Generalor INSPECTOWS USE ONLY TOTALt ,r�
$ign/Oudine Ltg. Xfmr. F[L�' �'�°" °J �
Alarm/Remote Connol
msmllafion demribed herein on the
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.. �_ THI�JNSTni � nT10N MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLV This reqaesrvoid 18 monrhs 6on� wlldation daie printed in �his 6ox.
I���I�I����������I�����I�I�{��n�� � �5�
* 0 7 5 1 8 5 2 5* o�a -3 6
PLEASE PRINT OR TYPE
Reqaee� �� Ro�ghJn insp�non reqobedz ❑ Ves I�spxtion pher ihon RoogfNn: ❑ Ready Now 'll Call
� (1'ou mus� coll �ha inspeclor whm reody) Da�e Reody:
I, licensed mnfraclor Q owner hereby request inspection of the above electricol work al:
Job Address ISVeer, Box Roote N � Ci Zip Code
( n� I �5�0 y %�t�P , � i � f �,� , �—�ti �7J
i, MN 55304
er Perforr�ng Insiallation� � �� � ^ �
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STATE BOARD COPY - SEE INSTRUCTIONS ON BA[
Gc. Na.