P - 84302♦' REGIUEST FOR ELECTRICAL INSPECTION -
-� 4 2 w��� m Minnesota State Board of Electricity
� 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 Hfr. 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 Inspeciion Request will 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 �
�ign/Outline Ltg. Xfmr. 0'
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the elechical installation described herein on the dates stated
Irri9ation Boom RougMn �a�
Special Inspectio - Dare
�` F��ai � L 2 f %
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 monfhs from validation ciafe prinfed in fhis box.
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* 0 4 4 2 3 1 5 8�k PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required? ❑ Yes o Ins fEon Ofher Than Rou h-In: Read Now
pec g y ❑ Will Call
�`, s� � 7 (You must call the inspector when ready Dafe Ready:
I,�censed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No. City Zip Code
21 �l,�C£ 1+0��
Secfion No. iownship Name or No. l2ange No. Fire No. Couniy �
I � Power Supplier
I � Mailing
Phone No.
r-�u,_
Name) � Conhactor License ho. � Master Lic. No. (Plant Elect.
�ddress (Conhactor or Owner Performing InstallaTion�
7525 NF?vac�a AvP_ 1V_ #'��1 � C�n�
�d Signafure �� nfractor or Own r PerForming Installafion)
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A- 6 STATE BOARD COPY - SEE INSTRUCTIONS 0