P - 80074•802°�48 �
REQUEST FOR ELECTRICAL INSPECTION `��
Minnesota State Board of Electricity a
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �.
Phone(612)6A2-0800
y/ Home Duplex Apt. Bldg. Other: �� New
Commerciai Industrial Farm emod
Air Cond. Htg. Equip. Water Htc Load Mgmt. Other. OD A A1 �'
Dryer Range Elec. Heat Temp. Service �� �����• �
"X" above ihe work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculafe Inspection Fee - This Inspecfion Request will not be accepted without ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps,1A
$treet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generalor INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. � r
Alarm/Remote Conhol
Swimming Pool
� I hereb ceAi that I ins the electrical installaKon described herein on the dafes staled
Irrigation Boom RougMn Dare
Special Inspection
final p�
Investigative Fee p "z--�.— dZ
THIS INSTALLATION MAY BE ORDERED DISCO CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void monihs from validafion date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Reques� Rou h-in ins fion r uired? .
� g pec eq ❑ Yes No Inspection Ofher Than RougMn: ❑ Ready Now Will Call
(You must call fhe inspedor when ready� Date Ready:
I, ❑ licensed contractor � owner hereby request inspection of the above elecfrical work at:
Job Address (Skeet, Box, or Route No.� � Cily � 2ip Code
'7 �� �, c ,� 3a
Section No. Township Name or No. Range No. Fire No. ouny
3� �
Occupanf � � . � Phone No.
Conhacfor
Mailing Address �Controctor or Ow
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Auihorized Sipnafur� ona for or
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� License No. Master Lic. No.
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COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
No.