P - 83042REQUEST FOR ELECTRICAL INSPECTION �
6�{] ���� � Minnesota State Board of Electricity � a
�� 1821 University Ave., Rm, S-128, St. Paul, MN 55104
. �
Phone (612) 642-0800 `.��a
Home Duplex Apt. Bldg. Other: New
Commercial Industrial Farm Remod
Air Con Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heot Temp. Service
"X" above the work covered by this request. Enter remarks in this space ond on the back of the white copy only.
Calculate Inspeciion Fee - This Inspection Requesi will not be aca
Other Fee # Service Entrance Size
Mobile Home Park Stall 0 to 200 Amps
Street Ltg./Traffic Sig. Above 200 Am
Transformer/Generator INSPECTOR'S USE ONLY
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Poo�
I hareb certi that I ins fhe
Irriqation Boom R,,,,,,�„
wiihout the correct fee:
Fee # Circuits/Feeders Fee
0 to 100 Amps
Above 100 Amps
TOTAL
�s-r°
on the dates stated
Date
THIS INSTALU1�T01a' IG�►�""BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 11AONTHS.
__ OFFICE USE ONLY This requesf void 1 6om validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required$ ❑ Yes No InspecNon O�er Than RougMn: � Ready Now ❑ Will Call
���'Z �g� (You must wll the inspectw when ready� Date Reody: 8' ��' ,6 �Q�
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I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addreu (Skeef, Box, or Route No.) Ci1y Zip Code
SGY/-y�sr iv� Fwo�le
Seclion No. Township Name or No. Range No. fire No. County
! Or►�/ �0.�"a�4c�v
Power Supplier
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Eleclriml Conhactor (Company Name)
�r'S �CCi�iz [ e,.
Mailing Address �Conhacfor or Owner PerFom
�T�O �,s7 � t}�e
Aufhorized Signafure (Conhacfor or Owner Pe
�
Phone No.
s�.�- 865�
nse No. Masfer Lic.
y�
� ss398'
Phone No.
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l A-11 8/96 STATE ARD Y- SEE INSTRUCTIONS ON BACK OF YELLOW COPY