P - 81285�30-534
REQUEST FOR ELECTRICA� INSPECTION ���+$�
Minnesota State Board of Electriciry
7821 University Ave., Rm. 5-128, SL Paul, MN 55104
Phone (612) 642-0800 _.
"X" above fhe work covered by Miis requesl. tnrer remarks in lhis space ond on fhe b/ockf i fh
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Calculale lnspection Fee - This Inspec�ion Request will nof be ac<ep�ed wilbout fhe cortecf fee:
Other Fee # Service Entrance Size Fee # Circuits
Mobile Home Park Sfall 0 to 200 Amps 0 ro 100 A
Street Lfg./Tmffic Sig. Above 200_Amps Above 100
Transfnrmer/Cenem�or INSPECTOR'SUSEONLY
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Fee
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Investigative Fee
THIS INSTALLATION MAY BE ORDEpED DISCONNECTED IF NOT COMPLETED WITHIN 16 MON7 .
OFFICE USE ONLV IFtls raquesf void I B months 6om wlidation dole prinled in this 6ox.
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s 0 7 3 0 5 3 4 5* �70/
PLEASE PRINT OR TYPE
Requesr k RwgMn Iropecno� �equtred? ❑ Yes I�spectio� 01her Than RoughJm ❑ Ready No ill Call
'3o fj �Vou musrmllihe i�apecio,when ready Da�e Ready:
I, licensed controcbr ❑ owner hereby request inspection of the obove electrical work of:
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