P - 79650.�
REQUEST FOR ELECTRICAL INSPECTION �
Q rj�-� v��� � Minnesota State Board of Electricity 3
� v 1821 University Ave., Rm. S-128, St. Paul, MN 55104 =
Phone (612) 642-080 ���
Home Duplex Apt. Bldg. Other: / v� 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 cove d by this request. Enter re arks in this space nd on the back of the whi►e copy only.
� ��{` C L''iY! �C� � / ✓ � G��S � 5 n� U—i - �� C�� C C9 /Ci $� U� ( i il � .
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Calculafe Inspection Fee - This Inspeciion Request will r,ot be accepted withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall '2 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 TOTA�
Siqn/Outline Ltq. Xfmr.
Alarm/Remote
Swimming Pool
Irriqation Boom
l lnvestigative Fee � 1
THIS INSTALLATION MAY BE ORDERED
I I�II �I III II (II II III II III �I II� II III II �I �� I�I
S'l-
I inspecled the eleclrical installation described herein on the dates staled
C. �/�-�-- � �l"` 2'7 .G�r�
DISCONNECTEO IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE U8E ONLY This request void 18 months From validation dafe printed in fhis box.
* 0 8 0 2 3 1 0 3* ���j ��'s�
PLEASE PRINT OR TYPE
Requesf D Rough-in inspecfion requiredZ ❑ Yes No Inspection Other Than RougMn: Ready Now 0 Will Call
2 �% Z (You must coll the inspector when ready� Date Ready: 3 z �
I, licensed contractor ❑ owner hereby request i�spection of the above electrical work at:
Job Addreu �Sheet, Box, or Route No.) City Zip Code
5�G O� �� �w
Section No. Township Name or No. ge No. Fire No. Cou
— �� �� � 4� f
Occupant
�o+.�t �t.J � �s v�
Power $upplier _
Conhacfor
or
s9���
0
Conhacfor
Phone No.
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'Iv - �'�� �
ON BACK OF YELLOW COPY
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