P - 80890REQUEST FOR ELECTRICAL INSPECTION ��`��,
8 f1 �� 9[] � Minnesota State Board of ElecVicity ry7;
12' 1� 1821 University Ave., Rm. 5-128, St. Paul, MN 55104
r Phone (612) 642-0800 �
Home Duplex Apt. Bldg.. Other New Addn
Commercial Industrial Form Remod Re air
Air Cond. H�g. Equip. Woter Htr. Lood Mgmt. Other:
Dryer Range Elx. Hea1 Temp. Service
°X" above fhe work covered by this request Enter remarks in this space ond on the - ck of /he whi�e copy only.
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Calculate Inspection Fee - This Inspection Request will nol be occepted wifhout the correcl Fee:
Other Fee #� Service En[rance Size Fee S Circui[s/feeders Fee
Mobile Home Park Stall 0 to 200 Amps $ 0 to 100 Amps
INSPECTOR'S USE ONLY
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POOI
sm�ed
I THIS INSTALLATION MAY 8E ORDERED DISCONNECTE� IF NOT COMPLETED WITHIN 18 MONTHS'�.
OFFlCE USE ONLY This requeY wid I B monihs fiom wlidolion dore primed in ihls 6ox.
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LEASE PRINT OR TYPE
ReqoesyE¢� Roughin Inepeclion reqotredz ❑ Yes �Na Inspection Other ihon RoughAm keody Naw � Will Call
�•j � lYov musr mll �he Inspecror when ready) Daie Ready:
I, licensed contmctor ❑ owner hereby request inspection o{ ihe obove eledrical work at:
Job s� 80., o� Roure Na. ` Gy Z�p Cade
� ;� I I ST N� ,�� 55
Sec�ion Na. Township Name or No- Range Nn Fire o. Caun �� � �
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Co�rcoc Lla No. Master Lic No.
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STATE BOAHdGOVY - SEE INSTROCTONS ON BGCK OF YELLOW C[lVV