P - 81771REQUEST FOR ELECTRICAL INSPECTION `���
1� O O/I �(1 �� � Minnesota State Board of Electricity �'
6� �`� 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
� (651) 642-0800 www.electricity.state.mn.us `�'
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Calcvlate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Insiallations Fee # Service Entrance Size Fee # Circuih / Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T�A� s—�
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
I herebvi certifv that I insoected the elechical installaKon described herein on fhe dates sfated:
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Imestigative Fee y —�/ �//
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITH N 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validation dafe printed in this box.
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�v �`�� PLEASE PRINT OR TYPE -
Requ��e /� Rou h-in ins ecfion re uired. �Yes ❑ No Ins ection Ofher Than Rou h-In:
y p 9 z p g ❑ Ready Now ❑ Will Call
�3 O You must call fhe inspector when ready Dafe Ready:
1, 13J licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: