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Home Duplex
REQUEST FOR ELECTRICAL INSPECTION '°°'�
Minnesota State Board of Electricity �'-���v,��
7821 Universiry Ave.. Rm. S-128, St. Paul, MN 55104 �S �
Phone (612) 642-0800 ��%�
Air Co Htg. Equip. Water Htr. Load Mgmt Other:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by fhis request Enfer remoiks in this space and on /he back oF �fi
�e� (ackrreKt R C
Calculofe Inspedion Fee - This lnspec/ion Requesf will nof be accepted wifhouf fhe mrrecf fee:
Other Fee # Service Entrance Size Fee # Cirwits
Mobile Home Park S�all 0 to 200 Amps 0 to 100 A
Sireet Ltg.JTraffic Slg. Above 200_Am s Above 100
Trnncfnrmer/Genemfor INSPECTOR'S USE ONLY
I msoected �he
copy
TOTAL
Dale
Fee
TMIS INSTALLATIOM MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monll+s from validafion da�e prin�ed in Ihis box.
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* 0 7 6 2 4 9 0 1 * 0�7�7
PLEASE PRINT OR TYPE
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s��9 g �Vov must mll ihe Inspecror when reody) Dme Ready:
I, � licensed <onfmdor � owner hereby request inspection of ifie above electricol work ai:
Job Addreu (Sheel, Box, ar Rook No.� Ciy � .s Zip Code
~7SD/�'�. rtCGQNI'.- � �r�a�%
Secfion Na. Township Name or No. Ranoe Na Fire No. owh
SCti''Q�tQ h �1R � �
ower Sapplier
`lechical Convanor �Company Name�
RTS Et6cTie � C
doiling Address �Canrcacror or Owne� PerFo�mirg li
g7�o -�S'>�"� �4v
1u�horized Siqnmure �Commcbr or Owner Perfq�i
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eho�eNo. (o(y —
Comroc�or Gcense No. Master Gc No. (Plvm E
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t�J �/ . ii'iM- 533 !Q
ifionl � 4 PhoneNo.6��'j —
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- SEE INSTRU�.TI(�y$.� OF VELLOW COPY