P - 83567:�
J�2-548 ����
RE(�UEST FOR ELECTRICAL INSPECTION �_
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 `'�'
me uplex Apt. Bldg. Other. New c
Commercial Industrial Farm Remo Re
Air Cond. Htg. Equip. Wafer Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered b this request. Enter remarks in this space and on the back of ihe white copy only.
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Calculate Inspection Fee - This Inspecfion Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 ro 200 Amps 0 to 100 Amps
Street Lig./7raffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
sa�io�d��e �m_ x�,�_ %1�a< �11 �p-4�
Alarm/Remote Confrol �� P J U
Swimming Pool
I hereb certi tlwt I in the electrical installafion describad herein on the dales stated
Irrigation Boom RougMn �
Special Inspection �
ImestigativeFee F�� �..YZ-oo � �l��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1 MONTHS.
OFFICE IlSE ONLY This roquest wid 18 months kan validation date printed in this box.
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* � 5 3 2 5 4 8 ,� �Ic PLEASE PRINT OR TYPE
Request Da�e Rou h-in ins fion r uired$ Yes
1� � �� g pec eq � ❑ No Inspeclion Other Than RougMn: ❑ Ready Now ❑ Will Call
(You musf call fhe inspecfor when ready� Date Reody:
I, ❑ licensed contractor Q� owner hereby request inspection of the above elechical work at:
bb Address (SUeet, Box, w Route No.) Ciy Z'�p Code
�lS�l c� ,,� S� � l� �r� ss�1,2 (
Section No. Townshio Name w No. Ran� No_ Ft.a No CM�
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� � �1 � ��.e�- �,s7� - /70�
Power Supplier � Addreu
� S . �c'7lf� fd �S�r'��t/
Elechical Conhac�or �Com ny Name) Contraclw license No. Moster Lic. No. (Mant Elecl
4
Maili�g Address (Conkac�or w Owner PerForming Inslallafion)
Authorized Signalu fraclw w Owner Performi Installation) Phone No.
�(�754 ,57� -170�
��� p"� � 8 C� ATE BOARD COPY - SEE INSTRUC710NS ON BACK OF YELLOW COPY