P - 83944� RE(�UEST FOR ELEC7RICAL INSPECTION �
� Q����� � Minnesota State Board of Electricity
`a 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone 612 642-0800 �
� ) ;�:
Home Duplex Apf. Bldg. Other: New Addn
Commercial Industrial Farm 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.
Calculate Inspection Fee - This Inspection Requesf will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall / 0 to 00 Amp Il 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �,
Sign/Oudine Ltg. Xfmr. �� �
Alarm/Remote Control �
Swimming Pool � �/�pl�i 3`-G -��
I hereb certi fhat I ins ed fhe elecfri 'nstallation descri herein on fhe dafes sfafed
Irrigation Boom Rougf�ln � Date
Special Inspectio ` � �
Final ° �� Dafe � f" y �
Investigative Fee ' � R-h'—°"�_ -- �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinfed in }his box.
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* � 4 9 1+ 5 0 � 5* PLEASE PRINT OR TYPE 7��
Request DaTe Rough-in inspection required? Yes ❑ No Inspection Ofher Than Rough-In: ❑ Ready Now ❑ Will Call
„� 7� �' �You must call fhe inspector when ready� Date Ready:
I, �] licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Rou�o.) City Zip Code
��' ,�t> � �1` ; c� � -e
Secfion No. To ip Name or No. Range No. fire No. C nty
Occupant
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Power Suoolier
ompony Name)
`S � ( -��r �� �
actor or Owner Performing Installafion)
�o `� r~ �-�
:ed Signafure (Conhacfor or Performing Installc
1 1 S/96 STATE BOARD COPY
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�TRUCTIONS 1
Phone No.
Master Lic. No.
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Phone No.
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