P - 82279fiEQUEST FOR ELECTRICAL INSPECTION
���= 9 5 6- 3 21 �l Minnesota State Board of Electricity �
.,J 1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 �:
(651) 642-0800 www.electricity.state.mn.us
"X" above the work
copy only.
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Calculate Inspection Fee - This Inspec►ion equ will not be accepted without fhe correc► fee:
Other Installations Fee # Service Enfrdnce Size Fee # Circuits / Feeders Fee
Mobile Home Park Sta{I 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TO/�ic/ � V
Sign / Outline Ltg. Xfmr. `
Alarm/Remote Control
$Wimmin9 POO� ��o�o�� „o,fi�, �,�� I t��oor� *o wlwckicnl insmllation destri6ed herein on ihe dafes sfated:
Speciallnspeci(M�O�i .1
F��ai �a�,-�!a -•��7
(nvestigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
^ ' OFFICE USE ONLY This request void 18 monfhs from validation date printed in this box.
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PLEASE PRINT OR TYPE
1, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work ot:
Job.Addres�Stregt, Box,pr Ropte N�/� /� Ciy � / Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Coun �
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ess (Co � cfo�, Company or Own er
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g ture �1 acror, ompany�pr e
No.
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� � Coy�a� r LicQn�N�O Master Lic.
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STATE BOARD COPY
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY