P - 808547��5-835 �
REQUEST FOR ELECTRICAL INSPECTION �,s�'��"�
Minnesota State Board of Eleciriciry ����__
1821 University Ave., Fm. S-128, SI. Paul, MN 55104
Phone (612) 642-0800 �i�ti?•
Air Cond. Htg. Equip. Wa1er HIr. Load MgmL Other.
Dryer Range Elec. Heot Temp. Servi<e
"X" above the work corered by fhis requesG Enfer remarks in �his space ond on the back of ih
cu� CB-au�.�a-,�eh, Cv�c.c� '
Calcu/ofe lnspection Fee - This Inspecfion Request wi�l no/ be occepfed wiihout �he torrect fee:
Other Fee # Service Enhance Size Fee p Circuits
Mobile Home Park Srall 0 to 200 Amps 0 l0 700 A
Slreet Lig./Tmffic Sig. Above 200_Am s A6ove 100.
Transformer/Generotor INSPECTOH'S USE ONLY
elennml
L'L' �7
Fee
.:10 • .S �
Do�e
THIS INSTALLATION MAV BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. �
OFFICE USE ONLY TNis reques� wid 18 monihs 6om mhdution data pimted in �hix box.
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PLEASE PRINT OR TVPE
Requesr Rough in inspxtion required? ❑ Yes ❑ No Inspedion Oiher Than Rwgh In: ❑ 6eody Now � Will Call
+� �— �' �Vou mas� call the inspecmr whm ready� Dale Raody:
I, � licensed contracror ❑ owner hereby requesl inspection of the above electrical work al:
Job Address �SneM, Boz, or Rome No.� Ciy Zip Code
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. I lownship Name ar No. I Roi
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ol�er Ad
ommcbr �Company Name�
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dress (Conhacror or Dwner Prrkrming I�stalla�ian�
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Signqrore �Canlmcror or Owner Per(ormly liytallafic
Ph No.
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No. Maskr Lic. Na (PIan1 E
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- SEE INSTRUCTIONS ON BACK OF YELLOW COPY