P - 84706REQUEST FOR ELECTRICAL INSPECTION � :�.
5, lf'� - 8 2 6 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 '
Commercial � � Indushial
Air Cond. Hta. Eau,
"X" above the work covered
Farm
Water Hfr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on
New
Remod
the whiie coPY
Calculate Inspection Fee - This Inspection Request will noi be accepted without fhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �
�
Sign/Oudine Ltg. Xfmr. 1��—
Alarm/Remote Control
Swimming Pool
I hereb ceAi thaf I in fhe elechical installalion described herein on the dates stafed
IrriQation Boom o,,..,.�. �_ .. .
� investigafive q�R;�,�i t,/ J � L .�/_-E'�-" ����' j`�-7
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months 6om validafion date printed in this box.
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* � 5 0 3 8 2 6 0* PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required$ ❑ Yes No Inspecfion Other Than RougMn: Ready Now ❑�II Call
`� ���7 (You musf call the inspector when ready) Date Ready: ��30 ,�E]+.�
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I, licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
lob Address (Sheef, Box, or Route No.� C� P
�Y Zi Code
G�7/-3�'sr.�E F�����y
$eclion No. Township Nome or No. Range No. Fire No. Counly
Occupant
a�err ,�a lr:�
Powar $upplier Address
Eleclricol Controclor (Company Name�
�T'SEc�c� r �
Mailing Address (Conhactor or r Performing Inslallofion�
�1"j�Q �7.�,c�ue N� �; �„,,,. .
4uthorized Signoture (Conhodor or Owprs performino Installafionl !1 I
/� ko �
Phone No.
�onhac�a license No.
�ti-d �y 8,
�I y , 5.�39�
►259
Lic. No. �Plant Elect.
No.
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