P - 80916n REQUEST FOR ELECTRICAL INSPECTION ��'°"��
8 L�- 2 01 � glp�eUnivessary A ea,r Rm. SQ 28,ISL Paul, MN 55104 ��+��
� Phone (672) 642-0800
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Home Duolex Aot. Blda. Other: New Addn
Commercial Indusirial Form
Air Cond. Htg. Equip. Waler Hlr. load Mgmf. Other:
Dryer Range Elec. Heat Temp. Service
"X" obove the wo�k covered by ifiis request. Enfer remarks in this space and on fl
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of fhe whife copy only.
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Calculale Inspection Fee - This Inspec�ion Request wifl nof be ac<ep�ed without fhe rorrecf fee: ��
Other Fee # $ervice Entrance Size Fee R Circuits/Feeders Fee
Mobile Home Park Srall 0 l0 200 Amps 0 to 100 Amps
Sfreef Lfg./Traffi< Sig. Above 200_Amps Above 100_Amps
Tronsformer/Generabr INSPECTOH'S USE ONLY TOT/� 1�
ine Llg. Xfmr.
mofe Confrol
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Boom
�ho�l tnsoxied�he elennml ms�alloiion dascri6ed heretn on �he doies s�atad
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTNS.
OFFICE USE ONLY This request void 18 momhs from volidmion dare prin�ed in �hls 6.�.
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PLEASE PRINT OR TVPE
Requesr po�yh�in inspec�ion requiredd ❑ Yes ❑ No Inspection O�her Thon Rougbin: ❑ Reody Now WIII Call
( (� �You muzt mll the �nspeaor when ready� Dare Ready:
I, �censed confractor � owner hereby requesl inspection of Ihe above elecfrical work ot:
Job Address �54eet, Bax, or Raure No.� Ciy Lp Code
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Sec�ion No. iownship Name w No. Range Na Fire No. Couny ���
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STATE BOAHD COPY - SEE INSiHUCilONS ON BACK OF YELLOW COPY
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