P - 80884RE�UEST FOR ELECTRICAL INSPECTION �r�"�`^�R�
Q� Z���`� � Minnesota Sta[e Board of Elec[rici
� `� 7827 University Ave_. Rm. 5-128, SL Paul, MN 55104 �� �}�''
Phone (612) 642-0800 �'�
Air Cond. Wg. Equip. Water Hfr. Locd Mgmt. Ot6er'.
D er Range Elec Heat Temp. 5ervice �
"X" above the wo�k covered by ihis request. ENei �n rks in lhis space and on fhe back of ihe while copy anly.
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Cafculote Inspec(ion Fee - This lnspection Requesl will not be accepted withouf rhe mrred fee:
Other Fee # Service Entrance Size Fee p Circuits/Feeders Fee
Moblle Home Park Sfall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Tmffic Sig. Above 200_Am s Above 100_Amps
T�a��fo�mPr/GAne.�ror INSPECTOH'S USE ONLY TOTAL , �p
I Imoeded iha elec�dml insmllmion daxnbed herel�
Boom
Investi otive f ��� � `�-' � ! _ C�'
THIS IN57ALLATION MAY BE UNDERED DISCONNECTED IF NQT COMPLETED THIN 18 MONTNS.
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* 0 8 2 1 2 7 3 0� �g/Q
PLEASE PRINT OR TYPE
qoesr Wk3 9 g Raughin Inspec�ian requiredz ❑ yes ❑ No I�speclio� Other Thon Rovghl��. Reody Now � WIII Call
�Yau mu:r call rhe I�speow when reody� �ote Ready:
icensed confracfor � owner hereby requesf inspection o( ihe obove elecfrical work at:
Address (SItmet, o.Roure�1 ) G � Zip Code�///z
CO X c�N � �% � �Y �
dian No. Township Nama a� No. Ronpe Nn fire Na CounN �. e
I Occupan!
Signamre I��o� or
INC.
Pho�e No.
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SEE INSiRUCTIONS ON BAGK OF