P - 80739• • •
• • • •
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"X" above the work covered by thi;
/
Calculate Inspection Fee - This Insp�
Other Fee
Mobile Home Park Stall
Sheer Ltg./Traffic Sig.
Tra�sformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Conhol
Swimminq Pool
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 Univers+ty Ave., Rm. S-128, St. Paul, MN 55104
Phone(612) 642-0800
Apt. Bldg. Uther: New
Farm Remod
Water Hfr. Load Mgmt. Other:
Elec. Heat Temp. Service
;� "�-�1�
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request. Enier remarks in this space and on the back of the white copy only.
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:t" equest will not be accepted without the correct fee:
# Service Entrance Size Fee # Circuits
0 to 200 Amps 0 to 100 A
Above 200 Am s Above 100.
INSPECTOR'S USE ONLY
i
described herein on ihe dares stated
Fee
Investigative Fee F�� ��----� °��.1 �-- ���
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
OFFICE USE ONLY This requast void 18 months 6om validation date prinfed in fhis box.
� ��� �� �I� I� N� �� (N I� ��� �{�I�� fl �I� fl ��� � ��� ����
* 0 8 3 8 8 6 7 0* o'l� '�
PLEASE PRINT OR TYPE
Reque M Rough-in inspeclion required$ ❑ Yes ❑ No Ins on Olher Than Rou Mn: Reo Now
� pect: g dy ❑ Will Call
' 9� �You musf call the inspecfor when ready� Dafe Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
J Address (Sheet, Box, or Routeyq .� n Ciy /� Zip Code `
n / i //. // i . � / 1 _ �/_ �
or No. - � Range
�
�PEN�q�LYE EeLECTRIC, {NC, `����
,r s �C r rf i� 1ns ahon� ry
on Rapids, MN 554 3 �'7,,. �
Phone No.
�9'� -osi�
. Mosfer Lic. No. (Plc
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Phone No.
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY