P - 82691REQUEST FOR ELECTRICAL INSPECTION �
4 2�= 4 3 5 Minnesota State �oard of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg.
Commercial Industrial Farm
Air Cond. Htg. Equip. Water Htr.
Dryer Ronge E{ec. Heat
"X" above the work covered by this reque Enh
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Load Mgmt. Other:
Temp. Service
narks in ►his space and on the back
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Calculaie Inspection Fee - This Inspection Request will not be accepted withou► the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feed�
Mobile Home Park Stall 0 to 200 Amps 0 ro 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100
Transformer/Generator INSPECTOR'S USE ONLV TC
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control
Boom
New
Remod
I inspected the eleclriwl insMllafion described herein on the da
Dane
��Pr
- - - - -.. ..-_ Fiiwl
Investigative �^
THIS INSTALLATION MAY BE ORDERED CTED IF NOT COMPLETED WITHIN 18 MONTHS.
O�F'ICE USE OMLY This request voio 18 monfhs from�wlidqfion dafe printed in this box.
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* � 4 L 5 4 3 5 7* PLEASE PRINT OR TYPE
Request Date � Rough-in inspecfion required$ ❑ Yes o Inspecfion Olher Than Ro Mn:
ug ❑ Ready Now�Nill Call
Z�Q.(�' , (You must call thz inspector when readyJ Date Ready:
I, �licensed conhactor ❑ owner hereby request inspection of the above elechicol work at:
kb Addreu (Streat, Box, w RouRe No.) Ci Zip Code
�a D l 2� '"�r5,�-- ,�iJ� �. �,�. C ��,�""j 'i��L
$ection No. Township Name a No. Range No. Fire No. Couny �
Occupont
�'C C e � s�-�
Power Supplier
Phone�� � / _ `� �
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tlechical (:onhac�or �COm ny Name� ConfracFor License No. �� Master Lic. No. (PIaM Elecf. Only
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Mailing Address �Con or Owner Performing Insta �
�'''ce � u�c b�a �� —l�v�e�oa�� -- 5`S,�' YS"
Aulhorized SignaNre (Contracror a Owner P ing Installalion) Phone No.
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i&OOOOIA-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY