P - 8132045.�=636
above fhe wo
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Colculare Inspecfion Fee - This Inspa
Other Fee
Mobile Home Pork Sfall
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 Universiry Ave., Rm. S-128, St. Paul. MN 55104
Phone (612) 642-0600
vVate! Hir. Load Mgmt. pthec
Elec. Heat Temp. $ervice
quesi. ENer remarks ip rhis space and on the back oflfie white copy only.
er-v� ce -to � oo c�.�,p .
on Reques� will nol be accepted withouf fhe correcf Fee:
I k �Se�ssic�\Enirance �j{e Fee # CircuitsJfeeders Fee
fo 200 Amps 0 to 100 Amps �
INSPECTON'S USE ONLY
Alarm/Remote Conhol -7 CJ' 'Y
Swimming Paol ,
I hereb cxil ihot I ins red �he elxtriml insmllono� descri6ed here�n m the dates smted
Irrigofion Boom i` �•- Roogh-In ook
Special Inspecti
F��ai _ � D _
Investigofive Fee
THIS INSTALLATION MAY BE OROERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE OSE ONLY ihls reqoes� �rold 78 months from volidofon dote printad in ihrs box.
����U�����i���������������������������h� � 3� ��
�k 0 4 5 5 �a 3 6 L�K p ASE PRINT OR TYpE
Request J�_ � Roogh�in inspecnoo reqoired? ❑ Yes No Inspecrian Other Than Rough In: ❑ Reody Now ill Call
�YOU moslmll�he inspec�orwhen ready� Cate Reody:
I ,. licensed contra<br ❑ owner hereby request inspection of the above ele<himl work at:
bb Add...ress (So-rc1, Box. or B k No.) Ciry Z�p Code —
I 1(0 1 ��s G,�-+�c F�e.ioe IM� SS`f31
Secfion No. Township Name w Ru�e No. Flre No. Cwn
Na.
7n� - �a��
l%sorhl� A'l.c sS�'cs
, I�na,�ae� 7� � Mo„e, ��� No.
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5537�
SEE INSTHUC710H5 ON BACK OF YELLOW COPY