P - 82175REQUEST FOR ELECTRICAL INSPECTION �::��
8��—� O O � '. 8121eUniversty A ea,rRm. Se128,'St. Paul, MN 55104 �
Phone (612) 642-080Q„ `"�'
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Home Duplex Apt. Bldg. Other: O� �� New Addn
Commercial Industrial Farm f' Remod Re air
Air Cond. Htg. Equip. Water Htr. 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.
. s
Calculaie Inspection �� ='TflFS �p�fion Reqvest will not 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 �NSPECTOR'S USE ONLY TOT,
Fee
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� Pool � 0���
I hereb certi thaf I ins fhe elecfrical inslallation dexribed the dates stated
Boom a,,,,,,tii„ � n„b
' 9 ' final / ��- V I � �
Investi ative Fee
_THIS INSTALLATION MAY BE ORDERED DISCO CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 monfhs from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rou f�in ins on r uired$ ❑ Yes �
g pecli eq ❑ No Inspection Other Than RougMn: ❑ Ready Now ❑ Will Call
�� ZG ► U(% (You must call the inspec�or when ready) Dote Ready:
I, ❑ licensed confractor � owner hereby request inspection of the above electrical work at:
1ob Addreu �Sheet, Box, or Route No.) Ciry Zip Code
� �SW N�. ��� D C � Ss�l �
Secfion No. Township Name or No. Range No. fire No. Couny
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Occupan � �` Phone No.
l��-�-C�.l�✓ �r �s�o il ?�3— �aZ-96z1/
Power Supplier .
N si'.
Electrical Conhactor (Company Nan
Mailing Address (Coniracbr or Ovn
Authorized Signature �Conhactor or
:ense No.
Phone No.
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY