P - 81409`742-252 �
REQUEST FOR ELECTRICAL INSPECTION " -•
Minnesota State Board of Electriciry
1821 Universiry Ave, Rm. 5-728, SL Paul, MN 55104
Phone (672) 642-0800 —
"X" above the work covered by Ihis request Enfer remarks in Ihis spoce ond on dte back of the while wpy
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Calculofe (nspecfion Fee - ihis Inspection Request will not be accepted without tbe corred fee:
Other Fee # Service Entrance Size Fee # Circui[s/Feedere
Mobile Home Park Sto�l 0 to 200 Am s 10 100 Amps
$freer Lfg./Traffic Sig. Above 200_Am s Above l OD_Amps
TransformerfGenerator INSPECTOR'SUSEONLY TOTA/Lc
Sign/Oudine Llg. Xfmr. N
Alarm/Remote Conirol
$wimming Poo� I he�eb <ant � ihm i'��s xred �he elendcal �inx�ollution dexrib=d 6eret� on �he dares +a�.
Irriqation Boom Rn���h-In Dme
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITMIN 18 MUNTMS.
OFFICE USE ONLV Thls requezl vaid I B ths from volidafion dote printed in fhis 6ox.
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PIEASE PRINT OR TYPE
:qoest Date RougM� i�spxnon req�bedz ❑ Yes ❑ No Inspenlon Oiher Than Roogh In: eady Now � Will Coll
1'/ (Yo� mus� mll ;ha Inspecm� whm �eady� Ome Ready
li<ensed contm<for ❑ owner hereby request inspection of the above electrical work oY.
b Addre �Srteep Boz, or Rw�re � n, n � Ci� � Zip Code ^
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Name or No. -�_� Range No. � Fire
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