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P - 83781�51��"-$7� tl Home REQUEST FOR ELECTRICAL INSPECTION Minnesota State Board of Electricity 1821 University Ave., Rm. S-128, St. Paul, MN 55104 Phone (612) 642-0800 ' `'�' . Other: New Addn Remod Commercial Industrial Farm 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 D �v� 'e�7 o rn � ��� Calculate laspection Fee - This Inspi Other Fee Mobile Home Park Stall Street Ltg./Traffic Sig. Transformer/Generator Sign/Outline Ltg. Xfmr. Alarm/Remote Control Swimming Pool Irriaation Boom whiie copy only. rn Request will not be accepted wifhout the correct fee: # Service Entrance Size Fee # Circuits/Feeders Fee 0 to 200 Amps .3 0 to 100 Amps _ Above 200 Amps Above 100 Amps INSPECTOR'S USE ONLY TOTAL I hereb certi thaf I ins ted the el 'cal insfallafion dexribed herein on the dates Rougffln �� � , �� Investigative Fee �" --�' — THIS INSTALLATION MAY BE ORDERED DISC NNECTED IF NOT COMPLETED WI HIN 8 MONTHS. OFFICE USE ONLY This requesf void 18 monfhs from validaficn dafe printed in fhis box. � "'1 ��'� IIIIIIIIIIIIIIIIIII�IIIIIII IIIIIIIIIIIIIII `- �,. � �K � 5 1 1 8 7�i 5�K PLEASE PRINT OR TYPE " Request Date Rough-in inspection required? es ❑ No Inspection Ofher Than RougMn: ❑ Ready Now ❑ Will Call �,. �. q n (You must call the inspector when ready� Date Ready: l i, � licensed contractor ❑ owner hereby request inspection of the above electrical work at: Job Address (Sheef, Box, or Roufe No.) City Zip Code 13 - F 'cl Section No. Township Name or No. Range No. Fire No. Coun _ Occupant Power Conhacfor �Company Name) Phone No. • � '1 Address Confractor License No. Master Lic. No. � lLl�9'��.17]d.Q � C�Tt 1 ddreu (Conhacro r Owner Performing Installation) � �.Q� tnn � ��'1 �S'�. d Signature �Confracfor or Owner Performing Insfal 4-11 /96 STATE BOARD COP • ON BACK OF YELLOW COPY 0