P - 84666.
��5"5-510
Home Duplex
REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Eiectriciry
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
. Other: New Addn
Commercial Indusirial Farm " Remod Re ir
Air Con 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 whiie copy only.
l�v� ��1�1 `77� —�k�S
Calculate Inspecfion Fee - This Inspection Request will not be accepted without the correct fee:
Othe� Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�S USE ONLY TO �� �
Sign/Oudine Ltg. Xfmr. '
Alarm/Remote Control
Swimming Pool
I hereb certi thai 1 ins the elechical installation described herein on the dates stafed
Irrigation Boom RougMn Dare
Special Inspecti _
Eiml
Investigative F � �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months 6om validafion daie prinled in this box.
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* O 4 6 5 5 L O�* PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspection required? ❑ Yes �' Inspeclion O�er Than RougMn: ❑ Ready Now � a I
�You musf call the inspector when ready� Date Ready:
I, icensed confractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sh , r Roule No.) Ciy Zip Code
5`-�� -)�,re n �� � ��. t.�.�l 55�-3�—
or No. Range No. Fire No. County
Phone No.
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Address
ei���ai co�ha�ro. �.�.�L AVE. N.E.
ANOKA. MN 55304
Mailing Address ontracbr or Owner Performing Installation)
Authorized g ture �Co ra� ner PerForming Installafi�
�
Conhaclor License No.
('�f} 017�
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