P - 79606�02-315 �
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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-080 '�'
Apt. Bldg. Other: + New Addn
Farm � � Remod Re air
Water Htr. Load Mgmt. er:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will nof be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall � 0 to 200 Amps / 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Ar
TransFormer/Generator INSPECTOR�s usE oN�v TOT�
Sign/Outline Ltg. Xfmr. �— �A.-/� Xl�-9. ^-
Alarm/Remote Conhol
Swimming Pool
Fee
/' �
" � I hereb certi fhat I ins the elechical insTallafion described herein on the dales stafed
Irrigation Boo Ra9�n Da
Special Inspection �'�
Final D
Investigative Fee 6—���
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation dafe printed in fhis box.
I II�I II III II III II III II III II III I� III II �I II �I I IIII n �
* 0 8 0 2 3 1 5 2* K����� ���s�
PLEASE PRINT OR TYPE ,
Requesf Date ' Rou h-in ins ection re uired$ Yes
g p q � ❑ No . Inspection Other li�on RougMn: ❑ Ready Now �f Will Call
yjZ �You must wll the inspector when ready) Date Ready: �
I, ❑ licensed contractor � owner hereby request inspection of the above elecfrical work at:
Job Addreu �Sheef, Box, or Roufe No.) Cily Zip Code
y6za ,�,� sr �/ � F�io�.�y s�ar
Section No. Township Name or No. Range No. Fire No. Couny
.�b as� R�,�
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Power Supplier
E'�-EL
Electrical Conhactor �Company
SE�-�
Mailing Address (Contracfor or
Signature
W
Phone No.
�/ �/���✓� 1763 s�z -z.�b g
Address
�GS, Nv�e D� ✓�Ji4�V
lame) � Confrac�w License No. Master Gc. No. (Planf EI
Iwner Performing Installation)
or Owner Performing Installa' � . Pho� No.
ZG ] 572--
STATE BOARD COPY - INS7RUCT10NS ON BACK OF YELLOW COPY