P - 81289�.
7"11-191 �
Form
REQUEST FOR ELECTRICAL INSPECTION ��"`"�'a�
Minnesota State Board of Electricity �y �,
1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 �"�"'-�
Ofher:
"X" obove fhe work wvered 6y this request Enter remarks in this spoce ond on �he back ol tF
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Calculale Inspeclion Fee - This Inspection Reques� will no� be accepfed without the corred Fee:
Other Fee # Service Entrance Size Fee # Circuits
Mobile Home Pork Smll � 0 to 200 Amps �b% � � 0 10 100 A
Sireet Ltg./Tmffic Sig. Above 200_Amp� 1 I Above 100
Trqnsformer/Generolor INSPECTOR'S USE ONLV
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copy
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Fee
Invesfigafive Fee f' -
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY ihis request void I B manfhs from volido�ion dote printed in this box.
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PLEASE PRINT OR TYPE
R��u Rough-in inspenion requiredz ❑ Ves Inspecfion O�her Than Roughln: ❑ Raody Now ill Call
�ro� m��� �ou ihe ��.P«m, Nme� aady� ooie a�dy:
I, ��4isensed confmctor � owner hereby requesi inspeclion of the obove electrical work aY.
lob Address �Streei, Box, or Rouh No-) Ciy Zip Code
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