P - 82803REQUEST FOR ELECTRICAL INSPECTION
6 L+ 2�� 2(� � Minnesota State Board of Electricity ��
U � 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800 " '
Hpme Duplex Apt. 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 ihe white copy only.
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Calculate lnspection fee - lhis Mspection Request will not be accepted wiihout the correct fee: �Y� / Z
Other Fee # Service Entrance Size fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps ,00 0 to 100 Amps
Street ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TQTAL �'0
$ign/Outline Ltg. Xfmr. �� ''�_
Alarm/Remote Control
$wimming Pool
1 here cerfi Ihaf I ins the elechical inslallafion described herein on the dates stated
Irrigation Boom Ro�M� D�
Special Insp
Final Da
Investigative e C �--�^ —7 �/�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFK;E USE ONLY This request roid 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Req�i'Dafe � ��y Rough-in inspeclion required? ❑ Yes o- Inspecfion Other Than RougMn: eady Now 0 Will Call .
2 " X (You must call the inspecFor when ready) Date Ready:
I,�icensed conhactor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Skeef, Box, or Roufe .) City Zip Code -
22� `�' r� A1/�< IU. �� ��� L� u�S�
Section No. Township Name or No. Range No. Fire No. Counly
/Ve�
Occu nt Phone No.
f�8� ��t�D 5�2 - S'6 f�
Power Supplier Address � �
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Electrical Conh ror �Company Name� Con actor License No. Master Lic. No. (Plant Elect. Only)
G ,S E7.��7�,elL. �i4o0 $Z� —
Mailing Address (Confrador or erForming Instollafio�) A/
o - �o � .� M t�. M �. ���G
Authorized Si nafure (Con r or Pe mi •siallafion) _ Phone No.
� 6l2-�8�-88`�`�
E&00001 A-1 1 8/96 S TE BOARD COPY - SEE INSTAUCTIONS ON BACK OF YEILOW COPY