P - 81261'i" REQUEST FOR ELECTRICAL INSPECTION
C!?.�i.�,� ^(1 Minnesota State Board of Electricity
�y J C—'a7i3 J 182� Universiry Ave., Rm. 5-128, 1. Paul, MN 55104
Pnooe (siz) sa2-oeoo . � n'� _
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Home Du lex Apt. Bldg. Olher: New Addn
Commercial Indushial Farm �� Remod Re oir
Air Cond. Hf . Equip. Water Hir. Load Mgmf. fher:
Dryer Range Elec. Heat Temp. Service
"X" abore the work covered by this request. En�er remarks in �his spoce ond on �he back oi the white copy only. .
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Cokulate Inspection fee - This InspecNon Request wifl not be occepled wifhout the correcf fee:
O[her Fee # Servim Entmnce Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps % 0 to 100 Amps /,
INSPECTOR'S USE ON�Y
iote Conhol
Pool
Invesligafive Fee �� 3a
THIS INSTALLATION MAY BE ORDEHED DISCONNEC7ED IF NOT COMPLETED WR IN 18 MONTH .
OFFICE USE ONLY This rcquast void 18 mon�hx fran validotion dae printed in this 6ox.
INIINIIININIIillllllllllllli�iilllll��ll�ll J���� ,�a���,
* 0 5 3 2 5 6 9 ]� �c PLEASE PRINT OR TYPE
R�Oe� �°� RougMn inspec�lon requlred? ❑ Yes ❑ No Inspecfian O�her Thao Rough-Im ❑ Ready Now O Will Call
�Yar mur coll Me Inspecmr when ready� pme Reody:
I, ❑ licensed coNmcbr ❑ ownar hereby raquest inspection of the above elechical work ol:
lab Addresz (Sncet, Box, or Roure No.) Ciy Zip Code
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or Na. � Ronge No. I Fre No.
BOAND COPY - SEE INSTf1UCilOHS 0
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Phme No.• 6
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