P - 80956RE�UEST FOR ELECTRICAL INSPECTION
7���^^ n Minnesota State Board of Elec[ricity �
ZS 3 L 1827 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duolex Aot. Bldo. Other: New Addn
Industrial I I Farm
ig. Equip. Water Hh. load Mgmf. O�her:
Ronge Elec. Heaf Temp. Service
work covered by rhis request ENer remorks in this space and on fhe back oi fhe white copy
P�b �a�.�v� �st ��1 ��gs
Colculate Inspection fee - This Inspec�ion Requesf will nof be accepred wi�hout fhe correcf fee:
Other Fee # Service EnVance Size Fee ri Circuits/Feeders Fee
Mobile Home Park Srall 0 to 200 Amps 0 to 100 Amps
Sireet Lfg./TmBi< Sig. Above 200_Amps Above 100—Amps
Transfarmer/Generalor INSPECTOH'S USE ONLY TOTAI [--�
CI��/n��dl�olM xFm. .�•7l1
Alarm/Remote Control
Swimminta Pool
Dote
Investigafive Fee - ��"'
THIS INSTALLATION MAY BE ORDERED DISC CTED IF NOT COMPLETED WITHI 8 MONTHS.
OFFICE USE ONIY This request void 18 monihs 6om validafion dafe prinled in �his box.
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* 0 7 5 1 8 3 2 7* l%Qo�
PLEASE PRINT OR TYPE
equesr Da�e Ro�gh�in inspeciion required? ❑ Yes Inspection Other Thon Roogh-Im ❑ Ready Now III Coll
� I �� (vou most mll the inspector whe� reody� Do�e Reody:
,�,licensed contmcbr ❑ owner hereby request inspeclion of the above elechical work aC
ob Address (Street, Bax, or Rou�e No.) Ciry Zip Code
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ecfion Na. iownxhip ame or No. Rariqe No. Fire No. CwnH
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ELECT., {NC.
_ AYE. N.E.
Owner Pertamiy Installafio . %wne No.
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STpTE 80ABD CAPY - SEE INSTBUCTIONS ON BACK OF YELLOW Cf}PX. _