P - 83365REQUEST FOR ELECTRICAL INSPECTION �
� � � � � � � � Minnesota State Board of Elec4�icity � "
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 Htr. load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Fnter remarks in ihis space and on the bock of the white copy only.
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Calculate Inspection Fee - This Inspection Requesf will not be accepted without the correcf fee:
Other Fee # Service Entran Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amp .00 0 to 100 Amps .S� a
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps i S^O
Transformer/Generotor INSPECTOR'S USE ONLY TO /�
Sign/Outline Ltg. Xfmr. 7 ���C7
Alarm/Remote Control
$wimming Pool
I hereb certi that I ins ected the electrical installation described herein on the dates sfated
Irrigation Boom Rough-In Dare
Special Inspecti
Final � Date �_� .
investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validation daTe printed in fhis box.
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PL SE PRINT OR TYPE
Request Dafe Rough-in inspection required$ ❑ Yes No Inspection Olher Than RougMn: eady Now ❑ Will Call
/�� 3�� 8 (You must call the inspector when ready) Date Ready: /�
I, icensed controctor ❑ owner hereby request inspection of the�above elecfrica! work at:
Job Address �Sfreef, Box, or Route No.� - � r Zip Code
2 o v T�i S N, �%
$ection No. Township Name or No. Ranpe No. Fire No. County
Occupant `
n c7�o
Power Supplier Address
�EI ical Con actor (Company Name) Conhactor Lia
s�i �e ec�it?I c � G C o0
Mailing Address Conhacto� or Owner Performing InsTallafion)
S�o �Ceh ���l��e lU� ������ S.�
Au�rig�ire (Conhactor or OwnjPerforming Insfallafior� �
�, 1 _ .
rl o �cr
Phone No.
s �i s��y
Master Lic. No. (Planf Elect. Only)
a2
�i �a%e / aRt�l�% S`.S�
Phone No.
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STATE BOARD COPY - SE S UCTIONS ON BACK OF YELLOW CUPY