P - 80928OFFICE USE ONLV This requesl void 16 momhs 6om wlidation daie primed in �hls 6ox.
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PLEASE PRINT OR TYPE
R uest Daa Rough In inxpeciion required? ❑ Yes �Glo Inspecfion Other Than Raugh�ln: aody Now � Will Coll
/ (Vw mosi mll �he Inspetlor when readyl Doie Ready:
I, �li<ensed conhaclor ❑ owner hereby request inspection of the above electricol work at:
lob Addresx �Street, Bax, or Rau�e No.) , Ciry ._ i i Zip Code
I
7�5'-312 �
Y
'� Home Duplex
i
Phone No.
iEE INSTBUCTIONS ON BACK OF YELLOW COPY
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electrici(y
1821 University Ave., Rm. 5-128, St. Paul, MN 55104
Phone (612) 642-0800
Other: NQN,
^ rr^ � �y�iy. vvarer ntr. Lootl Mgml. Ofher.
Dryer Range Elec. Heof Temp. Service
°X" obove the work covered by fhis requesG Enter remo�ks in this space ond on ihe back of !he white capy
Gon�! �T /1/e.r�- /�'1,'r G� Gw,ol�,�.
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Calcubte lnspedion Fee - 7his Inspeclion Requesf will nof be accepted without Ihe mrrecf fee:
Olher Fee # Service Entrance Size Fee q Circuiis/Feeders
Mobile Home Park Sfall 0 to 200 Amps 0 fo 100 Amps
Street Llg./Traffic Sig. Above 200_Amps Above 100_Amps
Tronsformer/Generafor INSPECTOR'S USE ONLY TOTqL_ .
Siqn/Oufline Ltct. Xfmr. Ilr%
Pool
rhar I
BE ORDERED DISCONNE TED IF NOT
fhe dates
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Fee