P - 82058�rC���90 �
Home Duplex
Commercial Industrial
Air Cond. Hta. Epui
"X" above the work covered
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REGlUEST FOFi ELECTRICAL INSPECTiON �
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �.
Phone (612) 642-0800 `'ffi'
Apt. Bldg. Other: New Addn
Farm Remod Re air
Water Htr. Load Mgmt. Other:
Elec. HeaF Temp. Service �
iis equest. Enter remarks in �his �pace and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will rot be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits
Mobile Home Park Stoll 0 to 200 Amps 0 to 100 A
Street Ltg./Traffic Sig. Above 200 Am s Above 100
Transformer/Generator INSPECTOR'S USE ONLY
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irrigation Boom �
Scecial Inscection
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Investigative Fee - y ,�C/ �= 'j
THIS INSTALLATION MAY BE ORDERED DISC D IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validafion date printed in this box.
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* 0 8 0 2 1 9 0 9* r�/ CJ)
PLEASE PRINT OR TYPE O� l`�/
Request Dafe (% Rough-in inspection req�ired$ ❑ Yes No Inspecfion Other Than RougMn: ❑ Ready Now Will Call
�� l/^ O O �You must call the inspecfor when ready) Dafe Rendy:
I, ❑ licensed contractor � owner hereby request inspection of the above electrical work at:
Job Address �Street, Box, or Route No.j Ciy Zip Code
�'1 �3at a�L S�= N�- /'T���e ss�al
Secfion No. Township Name q�Noo. Range No. Fire No. ounty
o` o� �}no �a
Occupant Phone No.
�e�� To��e��.�, � �a) s? � ��� y
Power Suoolier . Add _ �
L.S' /tJp2�� l� r/
Conhactor License No. Masfer Lic. No.
Address (Con e�1qr or Owner PerForming IA�qlla�n� �
� t.
ed SignaNre°I�onk��r or O�ar erforA�irg Installafion�
/ � //
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
No.
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