P - 80917[^� REQUEST FOR ELECTRICAL INSPECTION
yi J�� - 5 9 4 Minnesota Sfate Board of ElectriciTy
� 1821 Universiry Ave., Rm. 5-128. St Paul, MN 55104
Phone (612) 642 0
'Home plex P,pt. Bldg. Olher: ' S°L• New Addn
Commercial Indushial Farm �� Remod Re oir
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heal Temp. Senice
"X" above f6e work covered by this request Enrer remarks in ihis space and on fhe back oi the white copy only.
Cakulare Inspection Fee - 7his Inspe
O[her Fee
Mobile Home Park Stall
Sheet Lf9./Troffic Sig.
Boom
eques� will nof be accepred without fhe correcf fee:
Service Enhance Size Fee R Circuits/Feedere
0 l0 200 . _ Qi 0 �0 100 Amps
ISPECTOR'S USE ONLV
/L�. $i_!f-Uii
�a� i
o� �ne a�, .wrea
i
� THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT. COMPIETED WITHINQ$.MONTMS. �
OFFlCE OSE ONLY This raqueslwid 18 months Fom wlidotion dote prinled in Iliis 6ox-
� �� �� (����� � � �� � �����I I�� �,5� ,�5a�...3
* � 5 3 2 5 9 4 9* pLEp$E PRINT OR TYPE
Req�esr po�e Roughin inspecfion requked2 Yrs ❑ No Inspecnon O�her Than kough�ln: ❑ Reody Now Will Cvll
�� �S �� �tla m�S cail �he inspec�or when ready� Dare Reody:
I, ❑ licensed conhoctor �owner hereby request inspection of the obove elxlrical work at:
Job Address �SheM, Bw, a Rooce No.� CI
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or Owner
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SfATE BOMD COPY - SEE IN CTIONS ON BRCK OF YELLOW COPV