P - 84147, REQUEST FOR ELECTRICAL INSPECTION
� R Minnesota State Board of Electricity
+� ����� v 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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� Phone(612)642-0800 "�'
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ome Duplex Apt. Bldg. Other: (� New Addn
Commercial Industrial Farm �`— �C2 S��'� '� ` Remod Re air
Air Cond. Htg. Equip. Water Hfr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspec►ion Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �-��
Sign/Outline Ltg. Xfmr. 2 � � � `� � �
Alarm/Remote Control � � C
Swimming Pool
I hereb certi thaf I ins ihe electrical installafion described herein on fhe dates sfated
Irrigation Boom Rougl�ln �a �-
Special Inspection G '( � �� f
Final Date /
Investigative Fee ��` '!�'�C
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validafion dafe prinfed in this box.
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* � 5 3 2 4 7 8 5* PLEASE PRINT OR TYPE �� ...�1
Request Da}e Rough-in inspection required? ❑ Yes ❑ No Inspection Olher Than Rough-In: ❑ Ready Now ❑ Will Call
�You must call the inspecfor when ready) Date Ready:
I, ❑ licensed contractor �wner hereby request inspection of the above electrical work at: � Z�� ',
Job Address (Sfreef, Box, or Route No.) City Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Couniy
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Occupant �---] . Phone No.
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Power Supplier Address
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Elechical Coniractor (Company Name) Confractor License No. Master Lic. No. (Plant Elect. Only�
�� r� �C� actor or Owner Performing Inslolla� � � �
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Aufhor e ig ure (Conha or o er Perfor in§ n 'on) I Pho� .
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EB-0OOOlA-1 1 8/96 _— STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY