P - 80913��`�-909 �
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ICalculote Inspec�ion Fee - This Inspe
O[her Fee
Boom
RE�UEST FOR ELECTRICAL INSPECTION ac""'"�^,
Minnesota State Board of Electricity �� �
1821 University Ave., Rm. S-128, SL Paul, MN 55104 '���
Phone (612) 642-0800 ����'��°`
Water Hfr. Lood Mgmt Olhec
Elec. Heat Temp. Service
request. Enfer remarks in f6is spoce and on dte bock oF �h
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ction Request will not be accepled withou� the wrred fee:
# Service Entrance Size Fee # Circuifs
0 to 200 Amps 0 to 100 A
Above200_ Amps Above 100
INSPECTOH'S USE ONl.Y
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copy
Fee
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Invesfigafive
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
. OFFICE USE ONLY This requesl wid 18 mon�hs hom volldafion date prin�ed in ihis box.
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* 0 8 Z 5 9 0 9 5* �/��'
PLEASE PRINT OR TYPE
Requesl Du�e9 9 p goughin inspecKOn required? ❑ Yes ❑ No Inspecnon Oiher ihon RoogM1ln: Reody Nnw O Will Call
(i Yov musr mll ihe ins
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I, icensed contmctor ❑ owner hereby request inspecfion of the obove electriwl work at:
lob d�en �5veet, Bo., or Roup .� �;�„ � „ .,. ,. , �
No.
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No.
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SEE INSTqUCiIONS ON 6ACK OF VELLOW COPY
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