P - 81300, REQUEST FOR ELECTRICAL INSPECTION
���9 � C 7/I .. Minnesota State Board of Eleciricity _
L J f�f 1821 University Ave., Rm. 5-128, SL Paul, MN 55104
Phone (612) 642 J1800,h
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Drver Ro qe Elec Heat Temp. Service
"X" above the work covered by this requesL Enter remarks in �his spoce and on rhe back of fhe while copy only.
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Calculofe Inspecfion Fee - ihis Inspectio� Reques� wi I nof be accepted wifhout fhe correcf iee:
Other Fee A Serv e nVanc Si Fee Ji CircuitsJFeeders Fee
Mobile Home Park Stall 0 200 mp $,?a 0 to 100 Amps
Skeef Ltg./Tmffic Sig. A ve 200_Amps Above 100_Amps
Tmnskrmer/Genemtor INSPECTOR'S USE ONIY TOTAL" rd
S;gn/Outline Ltg. Xfmr. � (� (} � � `�� `�
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� I fgaf' e Fee � � C i�--'� "�'��- � '. ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLEfED WITHIN 18 MONiHS.
OFFICE USE ONLY Thls requesl vold 18 monlFu kom validalion dare prinfed in �his 6az.
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PLEASE PRINT OR TYPE
Request Dole Rwghin inspecfion req�ired2 Yes ❑ No Inspe�fion Oiher Twn RougMn: ❑ Rmdy Now �Wiil Call
S=% y�� S (Yo� mu�t mll Ihe inspedor when reody� Dale Reody.
I, ❑ licensed conhacror �nwner hereby request inspection of the obove eleckical work af:
Job Address �Srrael, Bw, or Rwle No.l Ciry / Zip Code
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