P - 81615�"'O 1 6_74 � � REQUEST FOR ELECTRICAL INSPECTION �`�=�'
Minnesota State Board of Electricity F:-- __ 3
' 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 - _
' (651) 642-0800 www.electricity.state.mn.us :- '`
Home Duplex Apt. Bldg. Other: New Adtln
Commercial Industrial Farm Remotl Repair
Air Contlitioner Htg. Equip. Water Htr. � Load Mgmt. Other:
Dryer Range Elect. Heat � Temp. Service
� aoove rne worK coverea dy m�s request. tnter remarks in this space and on the back of the white copy on/y.
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u/ate Inspection Fee - This Inspectio Request will not be accepted without the correct fee.
Other Irrstallations 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 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
�ign / Outline Ltg. Xfmr.
Alarm/Remote Control
I hereby certity that I inspected the electrical installation
In
Investigative Fee F'"y � �� I oa�2 �,ZZ do
THIS INSTALLATION MAY BE OROERED DISCONN HIN 18 MONTHS.
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III ��II OFFICE USE ONLY This request void 18 months from validation date pdnied in i�is'ooz°""" "'
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PLEASE PRINT OR TYPE
Request Date Rough-In inspection required? ❑ Yes � No Inspection Other Than Rough-In: � Ready Now � Will Call
��+��+�g You must call the inspector when ready! Date Ready:
I, ❑ I�:ensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code:
05._��U 8TH ST fV�. E=RIL3LEY ��4�`�
Section No.l Township Name or No.
Occupant
E1i �.
Power Supplier �
hJ�F'
Electrical Cantrector / Company Name
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E`dW;'a 1�t� lwLL.l, t Yrii
Mailing Address (Contractor, Company
Auth ' - ��--�.M' r!-Cdfi'
EB-00001A-12 5
Range No. Fire No. County
FFtt G�i_EY
Phone No.
Address
l�,�t'z i', t3f-�! CE
:ontractor License No. Master Lic. No. (Plant Elect.
�:ana � saa
or Owner Perfortning Installation)
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STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY