P - 84468� REQUEST FOR ELECTRICAL INSPECTION ����� "°`��
� �"° '"°�. Eg_00001-09 '
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.� See instructions for completing this form on back of yellow copy. ���
�, ' �� � X" Be/ow Work Covered by This Request ?���
Ne Add Rep. Type of Building Appliances Wired Equipment Wired
ome Range Temporary Service
Duplex Water Heater Electric Heating
Apt. Building Dryer Load Management
Comm./Industrial Furnace Other (Specify)
Farm Air Conditioner
Other (specify) Contractor's Remarks:
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Compute Inspection Fee Below: � ��� �
# Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Swimming Pool 0 to 200 Amps 0 to 100 Amps
Transformers Above 200 Amps Above 100 Amps
Signs Inspector's Use only: TOTAL .
Irrigation Booms ��� �
Special Inspection -
Alarm/Communication THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT
Other Fee COMPLETED WITHIN 18 MONTHS.
I, the Electrical Inspector, hereby Rough-in Date
certify that the above inspection has F��ai ••
been made. °
-=—__ ��...��.-�
OFFICE USE ONLY .
This request void 78 months from�-`
0-199-97" ��-sz� ^ ��
Re� Date �� � n� Fire No. Rough-In Inspection Required Inspection Other Than Rough-In
� � (You must call inspector when ready) Ready Now � Will Notify Inspector
❑ Yes ❑ No ate eady
I�Iicensed contractor ❑ owner hereby request inspection of above electrical work at:
Job Address (Street, Box or Route No. ��h, �,
2 ��' 3 � �c c�/
Sec' n o. Township Name or No. Range No. County
� � �
Occupant (PRINT) Phone No.
Power Suppiier . Address
Electrical Contracior (Company Name)
/�' 3 � Q C G .iG� �,
Mailing Address (Contractor or Owner Mak' g Installation)
2�S 33 (��t-e-�.S r� ,t.� S� .v �
Authori pd'9ignature (Contra r/Owner Making Installation)
. ��'� ` � � � � �I I' �^�!' �
MINNESOTASTATEBOARDO��T�ITY�` IIIIIII�IIIIIIIII�I�IIIIIIIIIIIIIIII�
Griggs-Midway Bldg. - Room & II
1821 University Ave., St. Paul, II
Phone (612) 642-08pQ_.: N
Gontractor's License No.
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Phone Number
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I THIS INSPECTION REQUEST WILL NOT
BE ACCEPTED BY THE STATE BOARD
UNLESS PROPER INSPECTION FEE IS
ENCLOSED.