P - 80909532-593
RE�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electriciry
1821 University Ave., Rm. 5-128, St. Paul, MN 55104
Phone (612) 642-0800
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"X" above Me work covered by Mis request Enter remarks in this space ond on Nie bock oi �he whife copy only.
Colculate Inspection Fee - This Inspection Requesf will not be occepied wi�houf the mrrec� fee:
Other Fee fl Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Slall 0 to 200 Amps 0 to 700 Amps
Street Lfg./Traffic Sig. Above 200_ Am s Above 100_ Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA�i ��
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dexdbed herein on ihe
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LTHIS INSTALLATION MAY BE.ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 98 MONTHS.
OFFICE lI3E ONLY This rpuest void 18 monihs from validotion date primed in ihis bon.
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* 0 5 3 2 5 9 3 ]i �% PLEASE PRINT OR TYPE
R�11B3� �O� q Rough:n inspanion re�uiredz Yes ❑ No In.penion Other Tlan Rough�ln: ❑ Ready Now Will Coll
�" �3 ' g/ r«, m�,� �on �ne ���o, ,.ne� .�dri oar� x�aY:
I, ❑ licensed contractor owner hereby request inspection aF the above electrical work af:
bb Address �Sneep Box, or Rome No.� Ciy Zip Code
E ��;�.le 5��3�.
Secfion No. Towns p Nome or No. Ronge No. _ Fire No. unly �
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Powe� Supplrer Addres ` � �
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STATE 60ARD COPY - SEE INSTRUCTIONS
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