P - 83286� REGIUEST FOR ELECTRICAL INSPECTION °'E
� � � � � � 'J � Minnesota State Board of Electricity �
1 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone (612) 642-0800
ome Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Form �CY,�c ^ 'Fv,�,�� 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 requesf. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection �ee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Pork Stall 0 to 200 Amps 0 to 100 Amps
- Streef Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�S use oN�r TOTA � r.
Sign/Outline Ltg. Xfmr. � J � 5�
Alarm/Remote Control
Swimming Pool
1 hereb certi fhat I ins ted fhe electrical insfallation described herein on the dafes sfafed
Irrigation Boo RougMn �re
Irnestigative Fee � �� � `�-�l' .� iQ
THIS INSTAILATION MAY BE ORDERED DISC CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validatio da prinied in ihis box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection required$ ❑ Yes Inspecfion Olher Than RougM�: ❑ Ready N Will Cal
t� �j � Y (You musf call the inspedor when ready� Date Ready:
1, [�lieensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or Rdure 7o.) Ciy Zip Code
� `1 �Y Qr � N � ��' i d � e � S 1� �---
Seclion No. Township Name or No. Range No. Fire No. Cou y
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���pAa^'t �� � Phone No.
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Power
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W
ed Signature (Conhacfor or Owner P rming Installafion) Phone No.
' yJ , �'6553 ���_ ��s�
I A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY