P - 84707REGIUEST FOR ELECTRICAL INSPECTION �
4 1 �� 9 7 5 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
` Phone(612)642-0800
ome Duplex Apt. Bldg. Other: New Addn
Commercial Indusfrial Farm Remod Re ir
Air Cond. Hig. Equip. Water Hh. 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.
Calcula►e Inspection Fee - This Inspec►ion Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park $tall 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,r�
s�
Sign/Oudine Lfg. Xfmr. �
Alarm/Remote Control
Swimming Pool
1 hereb certi that 1 ins fed the eleclrical installafion described herein on the dates stafed
Irrigation Boom Rough-In Dare
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 16 months from validation date printed in this box.
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* � 4% 9 9 7 5 5�K PLEASE PRINT OR TYPE
Requesf Date Ro h-in ins fion r uired?
ug pec eq ❑ Yes No Inspeclion O�er Than RougMn: Ready Now ❑ Will Call
���� � (You must call fhe inspector when ready) Da�e Ready: ���i �.�
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work ot:
Job Address �Sheef, Box, or Route No.� City Zip Code
!>a73 —3 �'��� ��,�1�
Section No. Township Name or No. Range No. Fire No. County ,
Omupant
Se�r, Do �c�0
Power Supplier
Elecfrical Conhacror (Company Name)
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Mailing Address (Conhaclor or Owner Performing In
��D'o�,5'1 � U� i✓
thorized Signature (Conhacror or Own Performi�
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E 1A-11 8/96 ' ST B R[
IPhone No.
Address
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Confmcfor License No.
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Masier lic. No. �P�ant Elect.
Phone No.
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