P - 80858✓ �
REQUEST FOR ELECTRICAL INSPECTION .. �� "
7(� ����� Minnesota State Boa�d ot Electricity �
.. 7821 University Ave., Rm. S-128, St. Paul, MN 551D4
Phone (612) 642-08W .e�k�
Home Duplex ApL Bldg. Other. New Addn
i Commerciol Indusfriol Farm Remod Reoair
Dryer � � Range � � Elec. Heaf � � Temp. $ervice �
pbove fhe work mvered by Ihis requesG Enrer rema�ks in fhis space and on �he bock of the white copy
Calculofe Inspecfion Fee - This Inspec/ion Request will nol be accepfeti without lhe mvect fee:
Other Fee # Service Entrance 5ze Fee Circuits/Feeders
Mobile Home Park Sfall O io 200 Amps 0 to 100 Amps
5lreet Ltg./Tmffic Sig. Above 200—Am s Above 100_Amp�.
Transformer/Generofor INSPECTOR'S USE ONLY TOTAL
�l11�/ii!!.(.J%
� THIS INSTALLAT70N MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. �
OFFICE USE ONLY ihis raqoeel wid I 8 momhs fmm validation dote printed in fiis boz.
iH�iiiil iiii�ili si i� ii �iiii ii��im , /ao. �
* 0 7 9 3 7 8 3 2* `�r
PLEASE PRINT OR TYPE
Requ sr Da� �� -� Roughin inspxfion required? ❑ Ves Inspection Orher ihvn RwghAn: Ready Naw � Will Call
�Yoo mus� wll ihe inspecro. when ready) Da�e Ready:
I, �ensed coNmcfor � owner hereby reqoest inspection of the above eleciricol work al:
Job Ad��au (Srceel, Box, or Rouk No.� �,.� Cly � lp Code _�
Ranga No.
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�� ��.15
STATE BOpRD COPY - SEE INSTNUCTIONS ON BAC