P - 7999680�-290 0
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REQUEST FOR ELECTRICAL INSPECTION �`�'��+°�
Minnesota State Board of ElecUicity �„�s
1821 University Ave., Rm. 5-128, St. Paul, MN 55704
Phone (612) 642-0800 ��'-
� nrhP.� New Addn
� � Elec. Heat� �Temp. Service � _
fhis request Enter remarks in fhis spa<e and on fhe back of the white copy
Cakulate Inspection Fee - This Insp
Other Fee
Mobile Home Park Slall
Sireet Lta./Troffic Siq.
m Request will r,of be amepted without fhe correcf fee:
# Servite Entrance Size Fee # Circuit
0 ro 200 Amps 0 to 100 A
Above 200_Amps Above l OC
INSPlC�TOR'S USE ONL�/� � �,-. ; �
/� "3
� 3Gt IVv
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I herebvi ce�nfv ihm I insoened ihe elecvkal iubllafio� desnibed herei�
�V
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1g'MONTMS.
OFFICE IISE ONLY Thix raquest void 18 manths from validation dofe printed in this bon.
��il� il���I ��������i����������������������� �,�. ��`�� � ���a��
PLEASE PRINT OR TYPE
Reqoen Dare RougMin inspenion requ��ed? ❑ Yes ❑ No Inspecnon Other Than Ro�gh i�: ❑ Reody Now � Will Call
�9ou musr coll Ihe inspecmr when ready� Doie Reody:
I, ❑ licensed contmcbr � owner hereby request inspection of tfie obove electrical work at:
bb Address (Sree�, Box, ar Roure No.� Ciy Zip Code
%S�Jc7 l�v .ni sr n�rs /%K�a���> � 5 ��1
SaFan No. Township Name or No. Range Na Fve No. Coonh
ay,�
-.� (� wt e S SG kd
Power Sup lier
��e'�
Elecrc�w Conn«ior �Company Nome�
IU-m� O W W�
Maili�g A dress (Con�mciw w Owner Performing Insk
4uthorized SlgrioNre (Comrocror or Owner Performing
Phoire No.
— �ZS�F- 7y�
Maner lic
STATE BOARU COPV - SEE INSTBUCilONS ON BACK OF YELLOW COPY