P - 81422RE�UEST FOR ELECTRICAL INSPECTION
. C O�� C C'1 . Minnesota State Board of Electriciry
�J J J J 1 1821 Universiry Ave., Rm. S-128, St. Paal, MN 55104
Phone (612) 642-0800 �,.�
Apt. Bldg. Other: ��/f � �
Farm
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
requr.sl. Emer remarks in Mis space and on fhe bock
Cakulate Inspecfion Fee - This Inspecfion Requesf will no� be accep�ed wirhouf rhe correcl fee:
Ofher Fee R Service E�rtrance Size Fee # CirtuitsjFeeders Fee
Mabile Home Park Srall 0 to 200 Amps 0 l0 100 Amps
Street Ltg./Traffic Sig. Above 200_Am s Above 100_Amps
Transformer/Genemtor INSPECTOWS USE ONLY TOTAL,I c-r�\
r.,..,in��d�..e ��., vam� �l _O�
Imesfigalive Fee ]—Z6 �00 � i i(—e�.
THIS INSTALLATION MAY BE ORDEHED DISCONNECTED IF NOT COMPLEfED WITHIN 1 MONTHS.
OFFlCE USE ONLY This requnt void 18 mon�hs (rom wlidafion dote prinred in Il�is ban.
I��u���l������� �1��������II��I����������� • ��.�
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* 0 5 3�C .5 5 1 9* PLEASE PRINT OR TYPE
��� xo�M� ��,a +�o� ,eym,�dz ve. ❑ Na i��«,m� a�. ma� no�anm: ❑ z�dy Now w�n can
'—�� q�' �1'ou musr call Ihe inspacior when .eody) Date 2eody
I, ❑ licensed conkocror� owner here6y request inspeclion of Ifie above elechicol work at
bb Addrass (SVee�, Boa, or Roula No � Ciy Zip Code
1331 Ht(�,�L—S� D�• NE �Qt�^�' S�-t3Z
SxFon No. Township Name w No. Ranqe Na Fre No. Counh
S�' -�j l�q
�r s��.t.�
or �wner renormm mswnaoon • ( rnone rvo.
�12�„�� � �'�� '%6 -
STATE BOAND COPV - SEE INSTilUC710N5 ON BACK OF YELLOW COPY