P - 83414REQUEST FOR ELECTRICAL INSPECTION ��°'E
7 O�� 3 2 2� Minnesota State Board of Electricity
J 1821 University Ave., Rm. S-128, St. Paul, MN 55104
. Phone (612) 642-0800 '�'
Home 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 the white copy only.
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Calculate Inspection fee - This Inspection Request wili not be accepted without the correc► 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/Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins ected the electrical installation described herein on the dates stated
Irrigation Boom RougMn Date
Special Inspec
Final
Investigative Fee �
THIS INSTALLATION MAY BE ORDERED DISC ECTED IF NOT COMPLETED ITHIN 18 MO THS.
OFFlCE USE ONLY This request void 18 months kom validation date printed in this box.
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* 0 7 0 5 3 2 2 6* �Qa �
PLEASE PRINT Oii TYPE
Request Dai' ��—�� Rough-in inspection required? ❑ Yes No Inspection Other Thon Rough-In: ❑ Ready Now ill Call
(You must mll the inspecfor when ready) Date Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Shcef, Box, or Roufe No.) City Zip Code
502 5�"h 5� I�L,e . i c�L.c 5-5�3�
Section No. Township Name or� No. Range No. Fire No. Cou
Occupant � /� V � � � �' _ " � Ph�G J � I
D � �„ �
�..�.,..
Power Supplier � ddress
Eleclrical Contracfor (Company Nome� Conhacfor License No. Masfer Lic. No. (Planl Eleci. Only�
BIAINE HT(3i. A;`C El,ECT.. INC. L�'
Maili�g Addre tion)
A MN 55304 �
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Aufhorize gnature � nhacf Owner Perfq�{ning Insfallafio Phone No.
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EB-00001 1 1 8/96 , STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF Ye��ew COPV