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REQUEST FOR ELECTRICAL INSPECTION �'""-
Minnesota State Board of Electriciry
1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0600 �v-
. Olher New Addn
Wafer Hir. Load Mgmt Ofher:
Elec. Heot Temp. Service
requesG Enter remorks in this spoce and on
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Calwlate Inspection Fee - This Inspec�ion Reques wJl nal be occepfed wifhoul Ihe rorrxf fee:
Other Fee N Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Sfall 0 b 200 Amps 0 to 100 Amps
ie Lig. Xfmr.
iole Confrol
Pool
Above 200_Amps Above 100_Amps
INSPECTOF'S USE ONLV TOTAL/J� �
L�e
ihot I ireoeded the
Imestiga�ive Fee - � - O `
THIS INSTALLATION MAY BE ORDERED DISCO ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This �equest void 18 monihs fmm validaFan da�e prinfed in Ihis box.
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* 0 7 6 8 4 4 0 0* °��9�0
PLEASE PRINT OR TYPE
Reqoesl Do�e ��� ^ gougbin inspenion required? ❑ Ves No Inspxfion Other Than Raugh In: Reody Now � Will Coll
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�/ � lyou musfmllihe I�specrorwhen ready) Daie Ready:
l, licensed contmctor ❑ owner hereby request Inspection of the above electrical work at:
Jab Add��t. Box �No.) CiN / Zip Cede
7 � �f /c��s/
No. I Ta'�T�shio Name or
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or Oyner Perforn
Phone Na.
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