P - 81303,
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REQUEST FOR ELECTRICAL INSPECTION �"'E'�'
Minnesota State Board of Elec[ricity ���, .
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 mti
ommercial Indusfrial Form
Ai! Cond. Hfg. Equip. Wofer Hfr. Load Mgmt Ofher:
Dryer Range Elec. Heaf Temp. Service
"X" above the work mvered by this requesG ENer remorks in this space and on
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Ca!<ulafe Inspection Fee - Thi Ins �ion Request will no� be accepfed wilhoW the correct fee:
Other Fee # Servicc Entrance Size Fee # Circuits
Mobile Home Park Slall 0 to 200 Amps 0 to 100 A
Sfreet Lfg./TraRic Sig. A6ove 200_Am s Above 100
Transformer/Gwner�mr INSPECTOH'S USE ONIV
herein onthe
Boom
copy
Fee
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_ �. THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WRRM 18 MON�HS.
OFFICE USE ONLY ihls requexl wid 18 months 6om wlidaiion date printed in �his boz.
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PLEASE PRINT OR TYPE
Requesr '� ^ Rougbin inxpection required? ❑ Yes No Inspecnon Olhar ihon Roughln: eody Now 0 Will Call
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! �Yo� mvst mll �he inspecror when ready) Dote Reody:
I, icensed conlmcror ❑ owner hereby request inspeclion of ihe abave elechical work ot:
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Secfion No. iownship Name or No. Range Na Fire No. C nry ,//
Phane No_
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