P - 79416�
RE�UEST FOR ELECTRICAL INSPECTION `
O Minnesota State Board of Electricity �
� v O�° 3 6 5� �gp7 Universiry Ave., Rm. 128, �'jNN 55104 `'
Phone (612) 642-0800 �d� � S'�' . -��__
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Cakulafe Inspecfion Fee - This Inspe
Other Fee
Mabile Home Park Stall
g. X{m�.
Control
Waler Htr. Lood MgmL Other
Elec. Heat Temp. Service
request Enter remarks in �his space and on
Requesf wi(1 not be accepted withouf the correct fee:
Ser�e �nhancr�jiFe Fee # Circuits
1 o zoo�mPS /� I 3b °" 121 o ro i oo n
� Above 200—�
INSPECTOfl'S USE ONLY
I tnscecrad �he elecv�ml tmmllmton deudbed
copy
Fee
' ' Fmol / ua�Q rZ.� C
Invesfigalive Fee -�,.fi�----�--�
THIS INSTALLATION MAY BE ORDERED DISCONNECTEO IF NOT COMPLETED WITHIN 18 MONTHS.
OFFIGE USE ONLV This reque# void�nonihs Fom volidotion daie prinled in this 6ox.
I�illllllllllllll IIIIIillllllllllllllllllllllll `�
* 0 8 0 2 3 6 5 * 'e �' �7a ��3�,50
PLEASE PRINT OR TVPE
Reques� Dare Rough-In inspectim required8 ❑ Yes No Inspecfion Other Than RougMn: ❑ Ready Now Will Call
G—/y-0 � na m�� �d� �e ;�=�ro, �,�, ,��, �e Rea�
I, [�licensed conlmctor ❑ owner hereby request inspection of the above electrical work af:
bb Addreu �9reet, eo., or Roure No.� Cly Zip Code
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Sxnon No. Township Name or No. Range No Fire No. Coun
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BAGK OF YE�LOW COPY
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